=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013382043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE CARE FOR THE ASSISTED LIVING AND GROUP HOMES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2015
-----------------------------------------------------
Last Update Date | 12/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5061 MERCER MILL BROWN MARSH RD
-----------------------------------------------------
City | CLARKTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28433-8733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-991-6259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5061 MERCER MILL BROWN MARSH RD
-----------------------------------------------------
City | CLARKTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28433-8733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-991-6259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRYAN MONROE
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 910-991-6259
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 5005915
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------