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General NPI Number Information
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NPI Number | 1699957407
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Entity Type | Organization
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Legal Business Name | ELLISON'S FAMILY CARE HOME
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 12/04/2007
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Provider Practice Location Address
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Address Line | 372 CANDY CREEK RD
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City | REIDSVILLE
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State | NC
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Zip | 27320-1626
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Country | US
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Telephone | 336-349-2220
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Fax | 336-349-2273
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Provider Business Mailing Address
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Address Line | 372 CANDY CREEK RD
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City | REIDSVILLE
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State | NC
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Zip | 27320-1626
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Country | US
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Telephone | 336-349-2220
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Fax | 336-349-2273
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. CLARISSA BROADNAX ELLISON
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Credential |
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Telephone | 336-349-2220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | FCL-079-004
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License Number State | NC
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