MEDICARE: BLASTOFF ADULT CARE HOME

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

General Provider Information

NPI Number	:	1265223143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLASTOFF ADULT CARE HOME

Provider Business Mailing Address
First Line	:	1114 HOPE MILLS RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4247
Country	:	US
Telephone Number	:	910-303-1702
Fax Number	:

Provider Business Practice Location Address
First Line	:	1114 HOPE MILLS RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304
Country	:	US
Telephone Number	:	910-303-1702
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. KIM LANDRY
Credential	:
Telephone Number	:	910-303-1702

Provider Enumeration Date	:	05/13/2025
Last Update Date	:	05/13/2025

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