=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235403908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B AND N FAMILY CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2012
-----------------------------------------------------
Last Update Date | 02/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 HOMEWOOD AVE
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-421-0435
-----------------------------------------------------
Fax | 336-421-5871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4094
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-0901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAWANDA RAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-421-0435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------