Provider Demographics
NPI:1124146048
Name:SHEILA CHILDERS SMITH
Entity type:Organization
Organization Name:SHEILA CHILDERS SMITH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-227-3845
Mailing Address - Street 1:925 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-3845
Mailing Address - Country:US
Mailing Address - Phone:336-227-3845
Mailing Address - Fax:336-227-3845
Practice Address - Street 1:925 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-3845
Practice Address - Country:US
Practice Address - Phone:336-227-3845
Practice Address - Fax:336-227-3845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-001-081320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805297Medicaid