NPIMap

Organization Active NPI

Country Living Guest Home, Inc.

  • Psychiatric Residential Treatment Facility
  • Washington, NC
National Provider Identifier
1902963499
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Residential Treatment FacilityTaxonomy code 323P00000X
License
MHL-007-043 Issued in NC
Legal business name
COUNTRY LIVING GUEST HOME, INC.
Practice address
3134 Market Street Ext
Washington, NC 27889-8127
Phone
(252) 975-3741
NPI assigned
Jan 3, 2007
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
Mr. Tim Hardison, R.N.
Title
Administrator
Phone
(252) 402-7823

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Residential Treatment Facility 323P00000X MHL-007-043 NC Primary

Addresses

Primary practice location

3134 Market Street Ext
Washington, NC 27889-8127

Mailing address

3134 Market Street Ext
Washington, NC 27889-8127
Phone (252) 975-3741

Other identifiers 1

IdentifierTypeStateIssuer
7805415MedicaidNC

National Provider Directory

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

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": "1598054400000",
    "number": "1902963499",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3134 MARKET STREET EXT",
            "city": "WASHINGTON",
            "state": "NC",
            "postal_code": "278898127",
            "telephone_number": "252-975-3741"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3134 MARKET STREET EXT",
            "city": "WASHINGTON",
            "state": "NC",
            "postal_code": "278898127",
            "telephone_number": "252-975-3741"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY LIVING GUEST HOME, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-03",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "HARDISON",
        "authorized_official_first_name": "TIM",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "252-402-7823",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "R.N."
    },
    "taxonomies": [
        {
            "code": "323P00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Residential Treatment Facility",
            "state": "NC",
            "license": "MHL-007-043",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7805415",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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 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.