Healthcare Provider Details

I. General information

NPI: 1760897771
Provider Name (Legal Business Name): WALK BY FAITH ADULT HEALTH & DAY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 W BROAD ST
DUNN NC
28334-4708
US

IV. Provider business mailing address

1004 W BROAD ST
DUNN NC
28334-4708
US

V. Phone/Fax

Practice location:
  • Phone: 910-891-2770
  • Fax: 910-891-2771
Mailing address:
  • Phone: 910-891-2770
  • Fax: 910-891-2771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberPE KX5D1Z7TA
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberPE-KX5D1Z7TA
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberPE-KX5D1Z7TA
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberPE-KX5D1Z7TA
License Number StateNC

VIII. Authorized Official

Name: DEANGELO JACKSON
Title or Position: OWNER/HEALTH CARE COORDINATOR
Credential:
Phone: 910-891-2770