Healthcare Provider Details

I. General information

NPI: 1124493945
Provider Name (Legal Business Name): COMMUNITY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 S CHURCH ST
BURLINGTON NC
27215-5048
US

IV. Provider business mailing address

1104 S CHURCH ST
BURLINGTON NC
27215-5048
US

V. Phone/Fax

Practice location:
  • Phone: 336-350-8295
  • Fax:
Mailing address:
  • Phone: 336-350-8295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-001-162
License Number StateNC

VIII. Authorized Official

Name: MRS. HAZEL J SPRUILL
Title or Position: OWENER
Credential:
Phone: 336-350-2690