Provider Demographics
NPI:1053595553
Name:SMALL FAMILY CARE HOME
Entity type:Organization
Organization Name:SMALL FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-492-2316
Mailing Address - Street 1:1421 ROSS MILL RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27537-5965
Mailing Address - Country:US
Mailing Address - Phone:252-492-2316
Mailing Address - Fax:
Practice Address - Street 1:1421 ROSS MILL RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27537-5965
Practice Address - Country:US
Practice Address - Phone:252-492-2316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCH091008261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803224Medicaid