Provider Demographics
NPI:1124493945
Name:COMMUNITY CARE HOME
Entity type:Organization
Organization Name:COMMUNITY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPRUILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-350-2690
Mailing Address - Street 1:1104 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5048
Mailing Address - Country:US
Mailing Address - Phone:336-350-8295
Mailing Address - Fax:
Practice Address - Street 1:1104 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5048
Practice Address - Country:US
Practice Address - Phone:336-350-8295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-001-162311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home