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General NPI Number Information
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NPI Number | 1164542882
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Entity Type | Organization
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Legal Business Name | MILDRED BLACKWELL
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3658 CHERRY GROVE RD
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City | ELON
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State | NC
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Zip | 27244-9483
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Country | US
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Telephone | 336-421-0646
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Fax |
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Provider Business Mailing Address
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Address Line | 203 N MAIN ST SUITE 315
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City | ROXBORO
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State | NC
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Zip | 27573-5343
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Country | US
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Telephone | 336-421-0646
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. MILDRED BLACKWELL
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Credential |
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Telephone | 336-421-0646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | HAL017003
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License Number State | NC
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