1003353475 NPI number — EASON COURT GROUP HOME LLC #2

Table of content: (NPI 1003353475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003353475 NPI number — EASON COURT GROUP HOME LLC #2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASON COURT GROUP HOME LLC #2
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003353475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 759
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YOUNGSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27596-0759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-556-5355
Provider Business Mailing Address Fax Number:
866-285-8824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 GREGORY MNR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27596-9614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-556-5355
Provider Business Practice Location Address Fax Number:
866-285-8824
Provider Enumeration Date:
01/24/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
SONJA
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
571-288-4144

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  MHL 035 050 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320800000X , with the licence number: MHL 035 029 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7804575 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".