=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407155120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREEKVIEW FAMILY CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2011
-----------------------------------------------------
Last Update Date | 03/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3524 DICKEY MILL RD
-----------------------------------------------------
City | MEBANE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27302-9006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-578-8374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4094
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-0901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-421-0435
-----------------------------------------------------
Fax | 336-421-5871
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------