| Organization Name: | RESIDENTIAL SERVICES AT REVERE, LLC |
| NPI Number: | 1003197609 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JACKIE J PARKER (DIRECTOR) |
| Mailing Address: | 516a Revere Rd Hillsborough |
| State: | NC US |
| Postal Code: | 27278 |
| Phone Number: | 9192414474 |
| Fax Number: | |
| NPI Enumeration Date: | 09/09/2011 |
| NPI Last Update Date: | 09/09/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320900000X |
| License Number: | 068151 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |