Provider Demographics
NPI:1124441050
Name:PETTIFORD HOMES DBA MCDANIEL HOMES
Entity type:Organization
Organization Name:PETTIFORD HOMES DBA MCDANIEL HOMES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-308-6672
Mailing Address - Street 1:PO BOX 1659
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-1659
Mailing Address - Country:US
Mailing Address - Phone:336-599-9863
Mailing Address - Fax:
Practice Address - Street 1:315 OLD ALLENSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27574
Practice Address - Country:US
Practice Address - Phone:336-599-9863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCDANIEL HOMES,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-29
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-073-066310400000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418621Medicaid