1023298718 NPI number — ANT MARYS FAMILY CARE INC

Table of content: (NPI 1023298718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023298718 NPI number — ANT MARYS FAMILY CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANT MARYS FAMILY CARE INC
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:
Provider Other Organization Name Type Code:
6
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:
1023298718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 516
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA GRANGE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28551-0516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3713 ED HERRING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28551-8331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-344-9903
Provider Business Practice Location Address Fax Number:
252-566-3598
Provider Enumeration Date:
11/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONYERS
Authorized Official First Name:
EULA
Authorized Official Middle Name:
MAE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-344-9903

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  FCL054059 , 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)

  • Identifier: FCL054059 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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