Healthcare Provider Details

I. General information

NPI: 1710265301
Provider Name (Legal Business Name): JUA VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 JUA VLY
DURHAM NC
27707-1507
US

IV. Provider business mailing address

12 MOONSTONE CT
DURHAM NC
27703-2682
US

V. Phone/Fax

Practice location:
  • Phone: 866-654-1113
  • Fax: 919-439-0222
Mailing address:
  • Phone: 866-654-1113
  • Fax: 919-439-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberFCL-032-110
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-032-110
License Number StateNC

VIII. Authorized Official

Name: MRS. KANISHA CONRAD DICKENS
Title or Position: ADMINISTRATOR
Credential: LPN
Phone: 866-654-1113