Provider Demographics
NPI:1891058210
Name:MCCLAIN'S FAMILY CARE HOME #1
Entity type:Organization
Organization Name:MCCLAIN'S FAMILY CARE HOME #1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:OLDPA
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:PATRICK MCCLAIN
Authorized Official - Phone:704-713-9920
Mailing Address - Street 1:5953 THE PLAZA
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-2451
Mailing Address - Country:US
Mailing Address - Phone:980-207-4747
Mailing Address - Fax:
Practice Address - Street 1:5953 THE PLAZA
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-2451
Practice Address - Country:US
Practice Address - Phone:980-207-4747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-060-123305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFCL-060-123Medicaid