Healthcare Provider Details

I. General information

NPI: 1316003668
Provider Name (Legal Business Name): LINDA SHORTS HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 GRANTHAM LN
JACKSONVILLE NC
28546-8150
US

IV. Provider business mailing address

180 COASTAL LN
JACKSONVILLE NC
28546-6761
US

V. Phone/Fax

Practice location:
  • Phone: 910-455-4480
  • Fax:
Mailing address:
  • Phone: 910-455-6724
  • Fax: 910-346-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL067026
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License NumberMHL067026
License Number StateNC

VIII. Authorized Official

Name: MRS. LINDA E GIBSON
Title or Position: DIRECTOR
Credential:
Phone: 910-455-6724