Healthcare Provider Details

I. General information

NPI: 1073641247
Provider Name (Legal Business Name): CAREGIVERS OF LIBERTY I
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 EAST RALEIGH AVE
LIBERTY NC
27298-3005
US

IV. Provider business mailing address

121 EAST RALEIGH AVE
LIBERTY NC
27298-3005
US

V. Phone/Fax

Practice location:
  • Phone: 336-622-0088
  • Fax:
Mailing address:
  • Phone: 336-622-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberFCL076028
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-076-028
License Number StateNC

VIII. Authorized Official

Name: MRS. KANDICE LACKEY JENKINS
Title or Position: OWNER
Credential:
Phone: 336-622-0088