Provider Demographics
NPI:1750507026
Name:OUTREACH HOME # 2
Entity Type:Organization
Organization Name:OUTREACH HOME # 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:N
Authorized Official - Last Name:OKEKE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:919-641-0162
Mailing Address - Street 1:305 SHALIMAR DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7571
Mailing Address - Country:US
Mailing Address - Phone:919-544-1033
Mailing Address - Fax:
Practice Address - Street 1:2002 OTIS ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3110
Practice Address - Country:US
Practice Address - Phone:919-530-1440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-346320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805419Medicaid