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General NPI Number Information
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NPI Number | 1649764762
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Entity Type | Organization
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Legal Business Name | TONYA CLARK FREEMAN
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Dates
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Enumeration Date | 06/21/2018
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 404 W RIVER ST
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City | COLERAIN
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State | NC
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Zip | 27924-8879
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Country | US
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Telephone | 252-642-4666
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Fax | 252-356-9954
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Provider Business Mailing Address
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Address Line | 404 W RIVER ST
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City | COLERAIN
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State | NC
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Zip | 27924-8879
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Country | US
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Telephone | 252-642-4666
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Fax | 252-356-9954
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TONYA CLARK FREEMAN
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Credential |
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Telephone | 252-356-9954
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | FCH008043
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License Number State | NC
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