Provider Demographics
NPI:1700114816
Name:KEAIRA'S HOUSE ADULT GROUP HOME
Entity Type:Organization
Organization Name:KEAIRA'S HOUSE ADULT GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-446-8162
Mailing Address - Street 1:2828 BERKLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-1312
Mailing Address - Country:US
Mailing Address - Phone:252-446-8162
Mailing Address - Fax:252-446-8162
Practice Address - Street 1:836 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-7456
Practice Address - Country:US
Practice Address - Phone:252-446-8162
Practice Address - Fax:252-446-8162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-033-067320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities