Healthcare Provider Details

I. General information

NPI: 1063774982
Provider Name (Legal Business Name): CHERRY'S FAMILY CARE #3
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HARMON STREET
AULANDER NC
27805-0236
US

IV. Provider business mailing address

PO BOX 236 106 HARMON STREET
AULANDER NC
27805-0236
US

V. Phone/Fax

Practice location:
  • Phone: 252-395-1704
  • Fax: 252-443-2463
Mailing address:
  • Phone: 252-395-1704
  • Fax: 252-443-2463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-008-032
License Number StateNC

VIII. Authorized Official

Name: MS. CALANDRA SHANICE CHERRY
Title or Position: ADMINISTRATOR
Credential:
Phone: 252-395-1704