1013048107 NPI number — HOME AWAY FROM HOME

Table of content: (NPI 1013048107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013048107 NPI number — HOME AWAY FROM HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOME AWAY FROM HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BLACKWELL RANKIN INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013048107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REIDSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27323-0155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-342-2213
Provider Business Mailing Address Fax Number:
336-349-7985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
334 ZEB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GIBSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27249-9507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-342-2213
Provider Business Practice Location Address Fax Number:
336-349-7985
Provider Enumeration Date:
03/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RANKIN
Authorized Official First Name:
SHUVON
Authorized Official Middle Name:
LEVETTE
Authorized Official Title or Position:
OWNER, ADMINISTRATOR
Authorized Official Telephone Number:
336-348-9924

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  FCL 079-051 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)