Healthcare Provider Details

I. General information

NPI: 1700894862
Provider Name (Legal Business Name): GOOD SAMARITAN FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N MAIN ST
RED SPRINGS NC
28377-1327
US

IV. Provider business mailing address

PO BOX 238
MAXTON NC
28364-0238
US

V. Phone/Fax

Practice location:
  • Phone: 910-843-9524
  • Fax: 910-843-9310
Mailing address:
  • Phone: 910-843-9524
  • Fax: 910-843-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL078036
License Number StateNC

VIII. Authorized Official

Name: MRS. TONDALAIRE BETHEA
Title or Position: ADMINISTRATOR
Credential:
Phone: 910-843-9524