=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427292200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WADE'S FAMILY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2009
-----------------------------------------------------
Last Update Date | 04/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 918 GRACE AVE
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27217-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-229-0430
-----------------------------------------------------
Fax | 336-229-0430
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2015 S MEBANE ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-7617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-280-0512
-----------------------------------------------------
Fax | 336-280-0512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. SAMUEL ALLEN WADE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-280-0512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | FCL-001-130
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------