Provider Demographics
NPI:1629394309
Name:DAVIS FARM ADULT GROUP HOME
Entity Type:Organization
Organization Name:DAVIS FARM ADULT GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:BURGESS
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-903-0349
Mailing Address - Street 1:232 GOLDEN VALLEY LANE
Mailing Address - Street 2:
Mailing Address - City:BATTLEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27809-7731
Mailing Address - Country:US
Mailing Address - Phone:252-442-5000
Mailing Address - Fax:
Practice Address - Street 1:232 GOLDEN VALLEY LANE
Practice Address - Street 2:
Practice Address - City:BATTLEBORO
Practice Address - State:NC
Practice Address - Zip Code:27809-7731
Practice Address - Country:US
Practice Address - Phone:252-442-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-033-074261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-033-074OtherMENTAL HEALTH LICENSURE NUMBER