Provider Demographics
NPI:1699957407
Name:ELLISON'S FAMILY CARE HOME
Entity type:Organization
Organization Name:ELLISON'S FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:BROADNAX
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-349-2220
Mailing Address - Street 1:372 CANDY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-1626
Mailing Address - Country:US
Mailing Address - Phone:336-349-2220
Mailing Address - Fax:336-349-2273
Practice Address - Street 1:372 CANDY CREEK RD
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-1626
Practice Address - Country:US
Practice Address - Phone:336-349-2220
Practice Address - Fax:336-349-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-079-004310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801455Medicaid