Healthcare Provider Details

I. General information

NPI: 1902099690
Provider Name (Legal Business Name): MITCHELL FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2007
Last Update Date: 08/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7727 BLANCH RD
BLANCH NC
27212-9687
US

IV. Provider business mailing address

7727 BLANCH RD
BLANCH NC
27212-9687
US

V. Phone/Fax

Practice location:
  • Phone: 336-234-7400
  • Fax:
Mailing address:
  • Phone: 336-234-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberFCL017027
License Number StateNC

VIII. Authorized Official

Name: MS. CLARISSA M. GUNN
Title or Position: ADMINISTOR
Credential:
Phone: 336-234-7400