MEDICARE: JUA VALLEY FAMILY CARE HOME #2

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	FCL-032-122	NC

General Provider Information

NPI Number	:	1225382070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUA VALLEY FAMILY CARE HOME #2

Provider Business Mailing Address
First Line	:	2 JUA VLY
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-1507
Country	:	US
Telephone Number	:	866-654-1113
Fax Number	:	919-439-0222

Provider Business Practice Location Address
First Line	:	2 JUA VLY
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-1507
Country	:	US
Telephone Number	:	866-654-1113
Fax Number	:	919-439-0222

Authorized Official
Title or Position	:	FAMILY CARE ADMINISTRATOR
Name	:	MRS. KANISHA DICKENS
Credential	:	LPN
Telephone Number	:	866-654-1113

Provider Enumeration Date	:	11/01/2012
Last Update Date	:	11/01/2012

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