=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295114098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCDANIEL HOMES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 05/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4694 CHUBB LAKE ROAD
-----------------------------------------------------
City | ROXBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-599-1073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX1636
-----------------------------------------------------
City | ROXBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-599-1073
-----------------------------------------------------
Fax | 336-599-8186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | PEGGY DAVIS-MCDANIEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 339-599-1073
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------