Healthcare Provider Details

I. General information

NPI: 1053595553
Provider Name (Legal Business Name): SMALL FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 ROSS MILL RD
HENDERSON NC
27537-5965
US

IV. Provider business mailing address

1421 ROSS MILL RD
HENDERSON NC
27537-5965
US

V. Phone/Fax

Practice location:
  • Phone: 252-492-2316
  • Fax:
Mailing address:
  • Phone: 252-492-2316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberFCH091008
License Number StateNC

VIII. Authorized Official

Name: MRS. IRENE SMALL
Title or Position: OWNER
Credential:
Phone: 252-492-2316