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General NPI Number Information
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NPI Number | 1760709364
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Entity Type | Organization
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Legal Business Name | ANT MARY'S FAMILY CARE #1
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Dates
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Enumeration Date | 04/23/2010
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Last Update Date | 05/04/2010
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Provider Practice Location Address
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Address Line | 104 WEST JAMES STREET ANT MARY'S FAMILY CARE HOME #1
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City | LAGRANGE
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State | NC
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Zip | 28551-3770
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Country | US
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Telephone | 919-344-9903
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Fax |
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Provider Business Mailing Address
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Address Line | 104 WEST JAMES ST. ANT MARY'S FAMILY CARE HOME #1
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City | LAGRANGE
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State | NC
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Zip | 28551-3770
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Country | US
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Telephone | 919-344-9903
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. EULA CONYERS
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Credential |
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Telephone | 919-344-9903
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | FCL054065
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License Number State | NC
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