Healthcare Provider Details

I. General information

NPI: 1912060062
Provider Name (Legal Business Name): FAMILY QUALITY CARE SERVICE ,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 LIBERTY ST
DURHAM NC
27703-2271
US

IV. Provider business mailing address

PO BOX 11265
DURHAM NC
27703-0265
US

V. Phone/Fax

Practice location:
  • Phone: 919-237-2225
  • Fax: 919-237-2225
Mailing address:
  • Phone: 919-237-2225
  • Fax: 919-237-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number032-328
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number032-328
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number032-328
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC2967
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number032-328
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number032-328
License Number StateNC
# 9
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number032-038
License Number StateNC
# 10
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number032-328
License Number StateNC
# 11
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number032-328
License Number StateNC
# 12
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number032-328
License Number StateNC

VIII. Authorized Official

Name: MS. SANDRA DENISE LASSITER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 919-237-2225