Provider Demographics
NPI:1215055215
Name:TERRY CARE HOME
Entity type:Organization
Organization Name:TERRY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAWANDA
Authorized Official - Middle Name:JEFFERSON
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-421-0435
Mailing Address - Street 1:56 STALEY BOSWELL RD
Mailing Address - Street 2:
Mailing Address - City:YANCEYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27379-8385
Mailing Address - Country:US
Mailing Address - Phone:336-421-0435
Mailing Address - Fax:336-421-5871
Practice Address - Street 1:2446 CHERRY GROVE RD
Practice Address - Street 2:
Practice Address - City:YANCEYVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379-8385
Practice Address - Country:US
Practice Address - Phone:336-421-3146
Practice Address - Fax:336-421-5871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL017009311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803138Medicaid