34D2086749 CLIA NUMBER - COUNTRY LIVING GUEST HOME, INC

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Laboratory Demographics

CLIA Number: 34D2086749

Facility Name: COUNTRY LIVING GUEST HOME, INC

Facility Address:
3094 MARKET STREET EXTENSION
WASHINGTON, NC
ZIP 27889
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Facility Phone Number: 252 975-3741

Facility Type: Other - SUPERVISED LIVING 5600C

Certificate Type: Waiver

NPI Number: 1912064064

Taxonomy: 320600000X - Residential Treatment Facility, Intellectual and/or Developmental Disabilities
A residential facility that provides habilitation services and other care and treatment to adults or children diagnosed with developmental and intellectual disabilities and are not able to live independently.

CLIA Record

Field Name	Field Value
CLIA Number	34D2086749
LAB Type	Other - SUPERVISED LIVING 5600C
Facility Name	COUNTRY LIVING GUEST HOME, INC
Street	3094 MARKET STREET EXTENSION
City	WASHINGTON
State	NC
ZIP	27889
Phone	252 975-3741
CertificateType	4
CertificateEffectiveDate	11/12/2022
CertificateExpirationDate	11/11/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024