Provider Demographics
NPI:1790981728
Name:HARRIS HOME
Entity Type:Organization
Organization Name:HARRIS HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-353-0124
Mailing Address - Street 1:106 STERLING RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-8330
Mailing Address - Country:US
Mailing Address - Phone:910-353-0124
Mailing Address - Fax:
Practice Address - Street 1:536 SHADOWRIDGE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7876
Practice Address - Country:US
Practice Address - Phone:910-353-9747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-067-143320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409469Medicaid