Healthcare Provider Details

I. General information

NPI: 1609052182
Provider Name (Legal Business Name): FAIRCHILD HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7053 JEFFREYS CREEK LN
RALEIGH NC
27616-5552
US

IV. Provider business mailing address

7053 JEFFREYS CREEK LN
RALEIGH NC
27616-5552
US

V. Phone/Fax

Practice location:
  • Phone: 919-376-3798
  • Fax: 919-376-3798
Mailing address:
  • Phone: 919-376-3798
  • Fax: 919-376-3798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-092-696
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberMH-092-696
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberMHL-092-696
License Number StateNC

VIII. Authorized Official

Name: MISS SOCORRO GARCIA
Title or Position: OWNER
Credential:
Phone: 919-278-6943