Healthcare Provider Details

I. General information

NPI: 1639823784
Provider Name (Legal Business Name): MR. ESTELLA JOANN SPANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 BERTHA WILSON RD
BLANCH NC
27212-9795
US

IV. Provider business mailing address

1136 BERTHA WILSON RD
BLANCH NC
27212-9795
US

V. Phone/Fax

Practice location:
  • Phone: 336-694-1878
  • Fax: 336-694-1878
Mailing address:
  • Phone: 336-694-1878
  • Fax: 336-694-1878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number017058
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number017058
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number017058
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number017058
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: