# COUNTRY LIVING GUEST HOME, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1902963499
- **Authorized official:** MR. TIM HARDISON R.N. (ADMINISTRATOR)
- **Authorized official phone:** (252) 402-7823

## Contact information

- **Practice address:** 3134 MARKET STREET EXT, WASHINGTON, NC 27889-8127
- **Practice address phone:** (252) 975-3741
- **Mailing address:** 3134 MARKET STREET EXT, WASHINGTON, NC 27889-8127
- **Mailing address phone:** (252) 975-3741

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 323P00000X | Psychiatric Residential Treatment Facility | MHL-007-043 | NC | Yes |

## Other

- **Enumeration date:** 01/03/2007
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 7805415 | — | NC |