Provider Demographics
NPI:1740424639
Name:HOMESTEAD PLACE
Entity Type:Organization
Organization Name:HOMESTEAD PLACE
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 1:3107 S ELM EUGENE ST
Mailing Address - Street 2:BUILDING A
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-5201
Mailing Address - Country:US
Mailing Address - Phone:336-273-2640
Mailing Address - Fax:336-273-6522
Practice Address - Street 1:2032 HOMESTEAD PLACE
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-9076
Practice Address - Country:US
Practice Address - Phone:919-240-5016
Practice Address - Fax:336-273-6522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTA PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-23
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-068-139323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7806104Medicaid