# COUNTRY LIVING GUEST HOME, INC.

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** COUNTRY LIVING GUEST HOME, INC.
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1972847390
- **Legal business name:** COUNTRY LIVING GUEST HOME, INC.
- **Authorized official:** MISS KELLIE MICHELLE HARDISON MSW, LCSW (ADMINISTRATOR)
- **Authorized official phone:** (252) 975-3741

## Contact information

- **Practice address:** 207 W 11TH ST, WASHINGTON, NC 27889
- **Practice address phone:** (252) 975-3741
- **Practice address fax:** (252) 975-3044
- **Mailing address:** 217 EAST 9TH STREET, WASHINGTON, NC 27889
- **Mailing address phone:** (252) 975-3741
- **Mailing address fax:** (252) 975-3044

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 251S00000X | Community/Behavioral Health Agency | — | NULL | — |
| 311ZA0620X | Adult Care Home Facility | — | NULL | — |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | — | NULL | Yes |
| 343900000X | Non-emergency Medical Transport (VAN) | — | NULL | — |

## Other

- **Enumeration date:** 11/26/2012
- **Last updated:** 07/27/2023