Provider Demographics
NPI:1104940782
Name:PASSIONATE CARE GROUP HOME
Entity type:Organization
Organization Name:PASSIONATE CARE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS/CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHANTA'E
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-332-2171
Mailing Address - Street 1:727 HONEYSPOT RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-7172
Mailing Address - Country:US
Mailing Address - Phone:203-378-0433
Mailing Address - Fax:
Practice Address - Street 1:105 WALNUT CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-7242
Practice Address - Country:US
Practice Address - Phone:919-332-2171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 051144320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805103OtherPROVIDER NUMBER