Healthcare Provider Details

I. General information

NPI: 1952560997
Provider Name (Legal Business Name): ETTALOVE FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 DIETRICH LN
CHARLOTTE NC
28262-3526
US

IV. Provider business mailing address

1951 DIETRICH LN
CHARLOTTE NC
28262-3526
US

V. Phone/Fax

Practice location:
  • Phone: 704-509-5596
  • Fax: 704-509-5596
Mailing address:
  • Phone: 704-509-5596
  • Fax: 704-509-5596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License NumberFCL-060-072
License Number StateNC

VIII. Authorized Official

Name: MRS. TERESA YVETTE WASHINGTON
Title or Position: ADMINISTRATOR
Credential:
Phone: 704-509-5596