Provider Demographics
NPI:1073817680
Name:HOME AWAY FROM HOME FAMILY CARE CENTER
Entity Type:Organization
Organization Name:HOME AWAY FROM HOME FAMILY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-751-7602
Mailing Address - Street 1:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28151-0711
Mailing Address - Country:US
Mailing Address - Phone:704-751-7602
Mailing Address - Fax:704-918-1273
Practice Address - Street 1:107 BRETT DR
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-9107
Practice Address - Country:US
Practice Address - Phone:704-313-7086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFLC-023-040310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility