Healthcare Provider Details

I. General information

NPI: 1275916942
Provider Name (Legal Business Name): SMITH STREET VILLAGE FAMILY CARE HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 COUNTRY TIME LN
LEICESTER NC
28748-6213
US

IV. Provider business mailing address

PO BOX 889
MOUNTAIN HOME NC
28758-0889
US

V. Phone/Fax

Practice location:
  • Phone: 828-676-5600
  • Fax:
Mailing address:
  • Phone: 828-676-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. NICHOLAS B STREET
Title or Position: PRESIDENT/ADMINISTRATOR
Credential: RN
Phone: 828-676-5600