Provider Demographics
NPI:1841486628
Name:BLEVINS HOUSE
Entity type:Organization
Organization Name:BLEVINS HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:SHERROLL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-956-7901
Mailing Address - Street 1:4404 GUESS RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-2620
Mailing Address - Country:US
Mailing Address - Phone:919-956-7901
Mailing Address - Fax:919-321-2193
Practice Address - Street 1:2325 COOK RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-2734
Practice Address - Country:US
Practice Address - Phone:919-806-2000
Practice Address - Fax:919-806-2000
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AIDS COMMUNITY RESIDENCE ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL032083261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801883Medicaid