Provider Demographics
NPI:1487890380
Name:LIVING WATERS GROUP HOME #2
Entity type:Organization
Organization Name:LIVING WATERS GROUP HOME #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-717-6127
Mailing Address - Street 1:8419 CARTMAN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-8419
Mailing Address - Country:US
Mailing Address - Phone:910-717-6127
Mailing Address - Fax:910-339-1844
Practice Address - Street 1:1264 DAVIS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:NC
Practice Address - Zip Code:28371-9621
Practice Address - Country:US
Practice Address - Phone:910-858-1403
Practice Address - Fax:910-339-1844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVING WATER GROUP HOME #2
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-078-219320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603850Medicaid