=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083983928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILDREDS FAMILY CARE,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2011
-----------------------------------------------------
Last Update Date | 11/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3592 MARSHALL GRAVES RD
-----------------------------------------------------
City | YANCEYVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27379-8630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-213-2132
-----------------------------------------------------
Fax | 336-421-5666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3592 MARSHALL GRAVES RD
-----------------------------------------------------
City | YANCEYVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27379-8630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-421-0646
-----------------------------------------------------
Fax | 336-421-5666
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CARL LAVALLE BLACKWELL JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-421-0646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | FCL-017-006
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------