MEDICARE: MRS. EMMA LUCILLE GARVIN ADMINISTRATOR

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	310500000X	Mental Illness Intermediate Care Facility	MHL 034-190	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	:	1922123892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EMMA LUCILLE GARVIN ADMINISTRATOR

Provider Business Mailing Address
First Line	:	1161 EDENWOOD DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6114
Country	:	US
Telephone Number	:	336-682-5870
Fax Number	:	336-724-9674

Provider Business Practice Location Address
First Line	:	4527 COUNTRY CLUB RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-3517
Country	:	US
Telephone Number	:	336-765-8460
Fax Number	:	336-724-9674

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/09/2007

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