=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962772418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SISTERLY LOVE LLC 2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2011
-----------------------------------------------------
Last Update Date | 12/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 326 BALDWIN RD
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27217-2716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-437-6811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3062
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-0062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-437-6811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NATASHA LATRAYAN MURPHY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-437-6811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | 001-222
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------