Provider Demographics
NPI:1982740205
Name:ALPHA DELTA FAMILY SERVICES GROUP, INC.
Entity Type:Organization
Organization Name:ALPHA DELTA FAMILY SERVICES GROUP, INC.
Other - Org Name:JACOBS TREE HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:QUALIFIED PROFESSIONAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TORAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-562-5300
Mailing Address - Street 1:7612 N NC HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-7519
Mailing Address - Country:US
Mailing Address - Phone:336-562-5300
Mailing Address - Fax:336-562-5500
Practice Address - Street 1:7612 N NC HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-7519
Practice Address - Country:US
Practice Address - Phone:336-562-5300
Practice Address - Fax:336-562-5500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-068-111322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603634Medicaid