Provider Demographics
NPI:1649589425
Name:SIERRA'S RESIDENTIAL SERVICES, INC.
Entity type:Organization
Organization Name:SIERRA'S RESIDENTIAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTTIE
Authorized Official - Middle Name:JEFFERY
Authorized Official - Last Name:VANHOOK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:910-814-4243
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-0655
Mailing Address - Country:US
Mailing Address - Phone:910-814-4243
Mailing Address - Fax:910-814-4245
Practice Address - Street 1:1995 US 421 N
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-7436
Practice Address - Country:US
Practice Address - Phone:910-814-4243
Practice Address - Fax:910-814-4245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC002092261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007305Medicaid
NC8300458Medicaid
NC8300458GMedicaid
NC5950677Medicaid
NC6603601Medicaid
NC6006839Medicaid
NC6603108Medicaid
NC6603401Medicaid
NC8300458HMedicaid
NC8300458BMedicaid