=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265865489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTWAY FAMILY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2013
-----------------------------------------------------
Last Update Date | 08/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 EASTWAY LN
-----------------------------------------------------
City | GRAHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27253-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-436-0219
-----------------------------------------------------
Fax | 336-270-3925
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 EASTWAY LN
-----------------------------------------------------
City | GRAHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27253-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-436-0219
-----------------------------------------------------
Fax | 336-270-3925
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR-OWNER
-----------------------------------------------------
Name | MR. JAY L MEBANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-213-3839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | FCL-001-151
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------