Provider Demographics
NPI:1013393842
Name:BLACKWELL'S COMMUNITY LIVING
Entity Type:Organization
Organization Name:BLACKWELL'S COMMUNITY LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PP
Authorized Official - Phone:336-317-1926
Mailing Address - Street 1:426 SOMERS AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-2032
Mailing Address - Country:US
Mailing Address - Phone:336-270-4463
Mailing Address - Fax:
Practice Address - Street 1:2406 ASHTON PARK LN
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-6310
Practice Address - Country:US
Practice Address - Phone:336-317-1926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251C00000XAgenciesDay Training, Developmentally Disabled Services