Provider Demographics
NPI:1215338231
Name:MARY'S HOME
Entity type:Organization
Organization Name:MARY'S HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:TIARRA
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:CNA MED TECH,
Authorized Official - Phone:252-347-9705
Mailing Address - Street 1:1808 BIRCHWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-6476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1808 BIRCHWOOD DR SE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-6476
Practice Address - Country:US
Practice Address - Phone:252-347-9705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC.1300322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children