Provider Demographics
NPI:1851589659
Name:EVANGELISTIC DELIVERANCE CENTER ADULT GROUP HOME
Entity Type:Organization
Organization Name:EVANGELISTIC DELIVERANCE CENTER ADULT GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:WILLIAMS
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-823-3699
Mailing Address - Street 1:1302 SAINT ANDREW ST
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-3032
Mailing Address - Country:US
Mailing Address - Phone:252-823-3699
Mailing Address - Fax:252-641-1681
Practice Address - Street 1:1302 SAINT ANDREW ST
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-3032
Practice Address - Country:US
Practice Address - Phone:252-823-3699
Practice Address - Fax:252-641-1681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-07
Last Update Date:2007-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities