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General NPI Number Information
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NPI Number | 1689932865
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Entity Type | Organization
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Legal Business Name | RUSSELL HOUSE
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Dates
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Enumeration Date | 04/25/2012
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1691 OLD BUFFALO FORD RD
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City | ASHEBORO
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State | NC
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Zip | 27205-7893
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Country | US
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Telephone | 336-672-0169
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Fax | 336-672-0169
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Provider Business Mailing Address
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Address Line | 1691 OLD BUFFALO FORD RD
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City | ASHEBORO
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State | NC
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Zip | 27205-7893
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Country | US
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Telephone | 336-672-0169
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Fax | 336-672-0169
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Authorized Official
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Title or Position | DIRECTOR
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Name | MAYNARD RUSSELL
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Credential |
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Telephone | 336-672-0169
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 275N00000X
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Taxonomy Name | Medicare Defined Swing Bed Hospital Unit
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License Number |
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | MHL-076-108
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | MHL-076-108
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License Number State | NC
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