1568781219 NPI number — VICKY D CONNALLY

Table of content: (NPI 1568781219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568781219 NPI number — VICKY D CONNALLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICKY D CONNALLY
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:
CORBETTS FAMILY CARE HOME 2
Provider Other Organization Name Type Code:
3
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:
1568781219
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 N MAIN ST
Provider Second Line Business Mailing Address:
SUITE 315
Provider Business Mailing Address City Name:
ROXBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27573-5343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-234-8592
Provider Business Mailing Address Fax Number:
336-234-0037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
382 HUDSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27305-9680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-234-8592
Provider Business Practice Location Address Fax Number:
336-234-0037
Provider Enumeration Date:
05/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CONNALLY
Authorized Official First Name:
VICKY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
336-234-8592

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  FCL017051 , 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: 7802647 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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