Provider Demographics
NPI:1821159278
Name:BENJAMIN HOUSE, INC.
Entity Type:Organization
Organization Name:BENJAMIN HOUSE, INC.
Other - Org Name:BENJAMIN HOUSE COMMUNITY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:HOLLOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:252-331-7731
Mailing Address - Street 1:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27907-0757
Mailing Address - Country:US
Mailing Address - Phone:252-331-7731
Mailing Address - Fax:252-331-1777
Practice Address - Street 1:848 FOREST PARK ROAD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5461
Practice Address - Country:US
Practice Address - Phone:252-331-7731
Practice Address - Fax:252-331-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3408242251C00000X
NCMHL-070-039311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408242Medicaid