Provider Demographics
NPI:1689970956
Name:DE-BORAH'S HOPE HOUSE
Entity Type:Organization
Organization Name:DE-BORAH'S HOPE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:ALSTON
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-908-1152
Mailing Address - Street 1:4701 FOX TROT RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8235
Mailing Address - Country:US
Mailing Address - Phone:336-908-1152
Mailing Address - Fax:336-834-2215
Practice Address - Street 1:3113 MCCONNELL RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-9611
Practice Address - Country:US
Practice Address - Phone:336-274-1988
Practice Address - Fax:336-834-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-1005320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC320800000XMedicaid