Healthcare Provider Details

I. General information

NPI: 1124441050
Provider Name (Legal Business Name): PETTIFORD HOMES DBA MCDANIEL HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 OLD ALLENSVILLE ROAD
ROXBORO NC
27574
US

IV. Provider business mailing address

PO BOX 1659
ROXBORO NC
27573-1659
US

V. Phone/Fax

Practice location:
  • Phone: 336-599-9863
  • Fax:
Mailing address:
  • Phone: 336-599-9863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberMHL-073-066
License Number StateNC

VIII. Authorized Official

Name: LISA PETTIFORD
Title or Position: MANAGER
Credential:
Phone: 919-308-6672