Healthcare Provider Details

I. General information

NPI: 1275968679
Provider Name (Legal Business Name): HUMPHREY FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3814 CHERRY GROVE RD
ELON NC
27244-9485
US

IV. Provider business mailing address

1156 HORSESHOE TRL
ALTON VA
24520-3084
US

V. Phone/Fax

Practice location:
  • Phone: 336-421-3001
  • Fax: 336-421-3001
Mailing address:
  • Phone: 973-868-2690
  • Fax: 434-575-5696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-017-032
License Number StateNC

VIII. Authorized Official

Name: MR. DAVID A HUMPHREY SR.
Title or Position: DIRECTOR
Credential:
Phone: 336-448-0096