Provider Demographics
NPI:1053595546
Name:HILLS DDA GROUP HOME INC
Entity type:Organization
Organization Name:HILLS DDA GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICETINE
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-522-4869
Mailing Address - Street 1:PO BOX 5425
Mailing Address - Street 2:2017 EAST RIDGE CIRCLE
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501
Mailing Address - Country:US
Mailing Address - Phone:252-522-4869
Mailing Address - Fax:252-522-4869
Practice Address - Street 1:2017 EAST RIDGE CIR
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501
Practice Address - Country:US
Practice Address - Phone:252-522-4869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL054111261QM0850X
261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805117Medicaid
NCMHL054111OtherLICENSE #