Provider Demographics
NPI:1194970681
Name:BO'S JOHNATHAN HOUSE, INC.
Entity type:Organization
Organization Name:BO'S JOHNATHAN HOUSE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:OBELIA
Authorized Official - Middle Name:WATSON
Authorized Official - Last Name:HOCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-369-5394
Mailing Address - Street 1:12749 BUCK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NC
Mailing Address - Zip Code:27557-8308
Mailing Address - Country:US
Mailing Address - Phone:919-269-7502
Mailing Address - Fax:919-269-7502
Practice Address - Street 1:300 WILL RD
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NC
Practice Address - Zip Code:27557-8317
Practice Address - Country:US
Practice Address - Phone:919-369-5394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BO'S JOHNATHAN HOUSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-25
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-051-168320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities