MEDICARE: MIMS FAMILY 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	FCL092045	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396940177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIMS FAMILY CARE HOME

Provider Business Mailing Address
First Line	:	6401 MIMS RD
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-9561
Country	:	US
Telephone Number	:	919-552-6455
Fax Number	:	919-567-5313

Provider Business Practice Location Address
First Line	:	6401 MIMS RD
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-9561
Country	:	US
Telephone Number	:	919-552-6455
Fax Number	:	919-567-5313

Authorized Official
Title or Position	:	ADMINSTRATOR
Name	:	MRS. JOYCE MIMS
Credential	:
Telephone Number	:	919-552-6455

Provider Enumeration Date	:	06/20/2007
Last Update Date	:	09/04/2007

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