Healthcare Provider Details

I. General information

NPI: 1992903926
Provider Name (Legal Business Name): EVERETT FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 BROAD ST
AULANDER NC
27805
US

IV. Provider business mailing address

PO BOX 749
AULANDER NC
27805
US

V. Phone/Fax

Practice location:
  • Phone: 252-345-1452
  • Fax: 252-345-1452
Mailing address:
  • Phone: 252-345-1452
  • Fax: 252-345-1452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFL008010
License Number StateNC

VIII. Authorized Official

Name: MR. KENNITH EDEN GREENE
Title or Position: ADMINISTRATOR
Credential:
Phone: 252-345-1452