Provider Demographics
NPI:1992005805
Name:COMMUNITY CONNECTIONS FAMILY LIFE CENTER LLC
Entity type:Organization
Organization Name:COMMUNITY CONNECTIONS FAMILY LIFE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LETONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-253-1268
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27261-0047
Mailing Address - Country:US
Mailing Address - Phone:336-884-7179
Mailing Address - Fax:336-884-7189
Practice Address - Street 1:622 N HAMILTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4076
Practice Address - Country:US
Practice Address - Phone:336-253-1268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC133NN1002X, 133V00000X
208000000X, 2083P0901X, 251S00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty