Provider Demographics
NPI:1720222615
Name:GARDEN LAKES
Entity Type:Organization
Organization Name:GARDEN LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:BS, QP
Authorized Official - Phone:336-273-2640
Mailing Address - Street 1:1000 REVOLUTION MILL DR
Mailing Address - Street 2:STUDIO#2
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5082
Mailing Address - Country:US
Mailing Address - Phone:336-273-2640
Mailing Address - Fax:336-273-6522
Practice Address - Street 1:3824 YANCEYVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3348
Practice Address - Country:US
Practice Address - Phone:336-375-4186
Practice Address - Fax:336-273-6522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTA PROFESSIONAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-229322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603533Medicaid