Provider Demographics
NPI:1942459284
Name:DRIVEN PURPOSE RESIDENTIAL LLC
Entity type:Organization
Organization Name:DRIVEN PURPOSE RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARQUES
Authorized Official - Middle Name:ANTWAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS BUS ADM/MGMT
Authorized Official - Phone:919-802-1577
Mailing Address - Street 1:3210 WALNUT CREEK PKWY APT G
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-3693
Mailing Address - Country:US
Mailing Address - Phone:919-802-1577
Mailing Address - Fax:
Practice Address - Street 1:520 LAURENS WAY
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7633
Practice Address - Country:US
Practice Address - Phone:919-266-6915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children