NPIMap

Organization Active NPI

Country Living Guest Home, Inc.

  • Intellectual and/or Developmental Disabilities Residential Treatment Facility
  • Washington, NC
National Provider Identifier
1558428045
Registry record updated Jul 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual and/or Developmental Disabilities Residential Treatment FacilityTaxonomy code 320600000X
Legal business name
COUNTRY LIVING GUEST HOME, INC.
Doing business as
Country Living Guest Home #2
Practice address
3052 Market Street Extension
Washington, NC 27889-8126
Phone
(252) 975-3741
Fax
(252) 975-3044
NPI assigned
Jan 3, 2007
Organization subpart
Yes
Parent organization
COUNTRY LIVING GUEST HOME, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 27, 2023

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

Authorized official

Name
Miss Kellie Michelle Hardison, MSW, LCSW
Title
Administrator
Phone
(252) 975-3741

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X
Adult Care Home Facility 311ZA0620X
Intellectual and/or Developmental Disabilities Residential Treatment Facility 320600000X Primary
Non-emergency Medical Transport (VAN) 343900000X

Addresses

Primary practice location

3052 Market Street Extension
Washington, NC 27889-8126

Mailing address

217 East 9TH Street
Washington, NC 27889-8126
Phone (252) 975-3741

Other identifiers 1

IdentifierTypeStateIssuer
7804660MedicaidNC

Other names 1

  • Country Living Guest Home #2 Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D2086746Country Living Guest Home, Inc #23052 Market Street Extension, Washington, NC 27889Certificate of waiverApr 10, 2027

National Provider Directory

National Provider Directory
Tax ID family
Country Living Guest Home Inc13 organizations share this tax ID, including this one
Part of
Country Living Guest Home Inc

Other organizations with this tax ID 12

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

NPI Registry JSON

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

{
    "created_epoch": "1167782400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690416000000",
    "number": "1558428045",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "217 EAST 9TH STREET",
            "city": "WASHINGTON",
            "state": "NC",
            "postal_code": "278898126",
            "telephone_number": "252-975-3741",
            "fax_number": "252-975-3044"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3052 MARKET STREET EXTENSION",
            "city": "WASHINGTON",
            "state": "NC",
            "postal_code": "278898126",
            "telephone_number": "252-975-3741",
            "fax_number": "252-975-3044"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY LIVING GUEST HOME, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COUNTRY LIVING GUEST HOME, INC.",
        "enumeration_date": "2007-01-03",
        "last_updated": "2023-07-27",
        "certification_date": "2023-07-27",
        "status": "A",
        "authorized_official_last_name": "HARDISON",
        "authorized_official_first_name": "KELLIE",
        "authorized_official_middle_name": "MICHELLE",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "252-975-3741",
        "authorized_official_name_prefix": "Miss",
        "authorized_official_credential": "MSW, LCSW"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "311ZA0620X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility, Adult Care Home",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "343900000X",
            "taxonomy_group": "",
            "desc": "Non-emergency Medical Transport (VAN)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7804660",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Country Living Guest Home #2",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Washington, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.