Provider Demographics
NPI:1104222066
Name:THYLLIS SMITH
Entity type:Organization
Organization Name:THYLLIS SMITH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER-PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:THYLLIS
Authorized Official - Middle Name:GARDENIA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-402-5592
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:RAMSEUR
Mailing Address - State:NC
Mailing Address - Zip Code:27316-1165
Mailing Address - Country:US
Mailing Address - Phone:336-402-5592
Mailing Address - Fax:
Practice Address - Street 1:339 RAMSEUR JULIAN RD
Practice Address - Street 2:
Practice Address - City:RAMSEUR
Practice Address - State:NC
Practice Address - Zip Code:27316-8832
Practice Address - Country:US
Practice Address - Phone:336-402-5592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-076-062N311ZA0620X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408719Medicaid
NC1104222066Medicaid