NPIMap

Organization Active NPI

Living Waters Group Home

  • Emotionally Disturbed Childrens' Residential Treatment Facility
  • Fayetteville, NC
National Provider Identifier
1447390042
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emotionally Disturbed Childrens' Residential Treatment FacilityTaxonomy code 322D00000X
License
MHL 026-796 Issued in NC
Legal business name
LIVING WATERS GROUP HOME
Practice address
1609 Sweetgum Cir
Fayetteville, NC 28304-2707
Phone
(910) 867-3279
NPI assigned
Feb 6, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Beverly Ann Ealy
Title
Residential Director
Phone
(910) 717-6127

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Emotionally Disturbed Childrens' Residential Treatment Facility 322D00000X MHL 026-796 NC Primary

Addresses

Primary practice location

1609 Sweetgum Cir
Fayetteville, NC 28304-2707

Mailing address

8419 Cartman Dr
Fayetteville, NC 28314-8419
Phone (910) 487-2630

Other identifiers 1

IdentifierTypeStateIssuer
6603850MedicaidNC

National Provider Directory

National Provider Directory
Tax ID family
Living Waters Group Home4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170720000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1447390042",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8419 CARTMAN DR",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283148419",
            "telephone_number": "910-487-2630"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1609 SWEETGUM CIR",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283042707",
            "telephone_number": "910-867-3279"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIVING WATERS GROUP HOME",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-06",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "EALY",
        "authorized_official_first_name": "BEVERLY",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "RESIDENTIAL DIRECTOR",
        "authorized_official_telephone_number": "910-717-6127",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "322D00000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Emotionally Disturbed Children",
            "state": "NC",
            "license": "MHL 026-796",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603850",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fayetteville, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.