=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538283262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOUBLE S & H FAMILY CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 158 EAST MAIN STREET
-----------------------------------------------------
City | YANCEYVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27379-0955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-694-9600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 955
-----------------------------------------------------
City | YANCEYVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27379-0955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-694-9600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. SUSAN ADAMS HALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-694-9600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | FCL017007
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------