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General NPI Number Information
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NPI Number | 1700914595
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Entity Type | Organization
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Legal Business Name | MT. OLIVE FAMILY CARE HOME #2
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 14471 NC HIGHWAY 41 S
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City | FAIRMONT
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State | NC
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Zip | 28340-5977
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Country | US
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Telephone | 910-628-7594
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Fax |
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Provider Business Mailing Address
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Address Line | 305 JACKSON ST
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City | FAIRMONT
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State | NC
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Zip | 28340-1621
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Country | US
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Telephone | 910-628-7755
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Fax | 910-628-7755
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. WILLIE EDWARD SPRUILL
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Credential |
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Telephone | 910-628-7755
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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 | FCL-078-015
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License Number State | NC
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