Provider Demographics
NPI:1063617207
Name:MARY'S FAMILY CARE HOME
Entity type:Organization
Organization Name:MARY'S FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CLINDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-637-5653
Mailing Address - Street 1:485 LONG FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-0546
Mailing Address - Country:US
Mailing Address - Phone:704-637-5653
Mailing Address - Fax:
Practice Address - Street 1:485 LONG FERRY RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-0546
Practice Address - Country:US
Practice Address - Phone:704-637-5653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL080004310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801970Medicaid