=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487840187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANADY FAMILY CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2007
-----------------------------------------------------
Last Update Date | 08/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 W BROAD ST
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28337-9245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-862-3264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 674 2810 W. BROAD STREET
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-862-3264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CHRISTINE CANADY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-862-3264
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | FCL009002
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------