Provider Demographics
NPI:1932371135
Name:ETTA'S RESIDENTIAL SERVICES AND SUPPORTS, INC.
Entity Type:Organization
Organization Name:ETTA'S RESIDENTIAL SERVICES AND SUPPORTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:919-599-1636
Mailing Address - Street 1:4833 TOLLEY CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-7827
Mailing Address - Country:US
Mailing Address - Phone:919-599-1636
Mailing Address - Fax:919-720-4818
Practice Address - Street 1:4833 TOLLEY CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-7827
Practice Address - Country:US
Practice Address - Phone:919-599-1636
Practice Address - Fax:919-720-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-705320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities