Healthcare Provider Details

I. General information

NPI: 1972706232
Provider Name (Legal Business Name): LUCY NANNIE HAIRSTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 CHANDLER MILL RD
PELHAM NC
27311-8785
US

IV. Provider business mailing address

3023 CHANDLER MILL RD
PELHAM NC
27311-8785
US

V. Phone/Fax

Practice location:
  • Phone: 336-939-7176
  • Fax:
Mailing address:
  • Phone: 336-939-7176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-017-026
License Number StateNC

VIII. Authorized Official

Name: LUCY HAIRSTON
Title or Position: OWNER
Credential:
Phone: 336-939-7176