Healthcare Provider Details

I. General information

NPI: 1386769040
Provider Name (Legal Business Name): ANT MARY'S FAMILY CARE #2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6198 WASHINGTON ST
LA GRANGE NC
28551-6823
US

IV. Provider business mailing address

PO BOX 516
LA GRANGE NC
28551-0516
US

V. Phone/Fax

Practice location:
  • Phone: 252-566-2933
  • Fax:
Mailing address:
  • Phone: 252-566-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL054046
License Number StateNC

VIII. Authorized Official

Name: MRS. EULA BRITT
Title or Position: OWNER
Credential:
Phone: 252-566-2933