Provider Demographics
NPI:1124212444
Name:FAMILY HOME LIFE, INC
Entity Type:Organization
Organization Name:FAMILY HOME LIFE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-533-9200
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-0066
Mailing Address - Country:US
Mailing Address - Phone:252-533-9200
Mailing Address - Fax:252-537-7458
Practice Address - Street 1:544 JULIAN R ALLSBROOK HWY
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4611
Practice Address - Country:US
Practice Address - Phone:252-533-9200
Practice Address - Fax:252-537-7458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409475Medicaid