Healthcare Provider Details

I. General information

NPI: 1518343458
Provider Name (Legal Business Name): BLACKWELL'S COMMUNITY LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 WILSON ST
GRAHAM NC
27253-2721
US

IV. Provider business mailing address

426 SOMERS AVE
BURLINGTON NC
27215-2032
US

V. Phone/Fax

Practice location:
  • Phone: 336-270-3644
  • Fax:
Mailing address:
  • Phone: 336-270-4463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ROBIN BLACKWELL
Title or Position: OWNER
Credential: PP
Phone: 336-317-1926