Provider Demographics
NPI:1790861334
Name:EASON COURT GROUP HOME
Entity Type:Organization
Organization Name:EASON COURT GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DAPHINE
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-556-4720
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27596-0759
Mailing Address - Country:US
Mailing Address - Phone:919-556-4720
Mailing Address - Fax:919-556-3003
Practice Address - Street 1:113 EASON CT
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27596-9228
Practice Address - Country:US
Practice Address - Phone:919-556-4720
Practice Address - Fax:919-556-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-035-029320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418180Medicaid