Organization
COUNTRY LIVING GUEST HOME, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. TIM HARDISON R.N. (ADMINISTRATOR)
(252) 402-7823
Entity
Organization
Contact information
Practice address
3134 MARKET STREET EXT, WASHINGTON, NC 27889-8127
(252) 975-3741
Mailing address
3134 MARKET STREET EXT, WASHINGTON, NC 27889-8127
(252) 975-3741
Taxonomy
Speciality
Code
Description
License number
State
323P00000X
Psychiatric Residential Treatment Facility
Primary
MHL-007-043
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7805415
—
NC
Enumeration date
01/03/2007
Last updated
08/22/2020
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