Healthcare Provider Details

I. General information

NPI: 1437438959
Provider Name (Legal Business Name): CLARK FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 SALEEN DR
WILLOW SPRING NC
27592-7610
US

IV. Provider business mailing address

167 SALEEN DR
WILLOW SPRING NC
27592-7610
US

V. Phone/Fax

Practice location:
  • Phone: 919-207-6114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-051-044
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberFCL-051-044
License Number StateNC

VIII. Authorized Official

Name: TURISSA BRIGHT
Title or Position: CEO
Credential:
Phone: 919-207-6114