MEDICARE: JUA VALLEY

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	385H00000X	Respite Care	FCL-032-110	NC
2	311ZA0620X	Adult Care Home Facility	FCL-032-110	NC

General Provider Information

NPI Number	:	1710265301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUA VALLEY

Provider Business Mailing Address
First Line	:	12 MOONSTONE CT
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27703-2682
Country	:	US
Telephone Number	:	866-654-1113
Fax Number	:	919-439-0222

Provider Business Practice Location Address
First Line	:	6 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	:	ADMINISTRATOR
Name	:	MRS. KANISHA CONRAD DICKENS
Credential	:	LPN
Telephone Number	:	866-654-1113

Provider Enumeration Date	:	07/29/2011
Last Update Date	:	07/29/2011

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Directions to “JUA VALLEY ” Practice Location

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