Provider Demographics
NPI:1225382070
Name:JUA VALLEY FAMILY CARE HOME #2
Entity Type:Organization
Organization Name:JUA VALLEY FAMILY CARE HOME #2
Other - Org Name:JUA VALLEY FAMILY CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY CARE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:866-654-1113
Mailing Address - Street 1:2 JUA VLY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-1507
Mailing Address - Country:US
Mailing Address - Phone:866-654-1113
Mailing Address - Fax:919-439-0222
Practice Address - Street 1:2 JUA VLY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1507
Practice Address - Country:US
Practice Address - Phone:866-654-1113
Practice Address - Fax:919-439-0222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUA VALLEY FAMILY CARE HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-032-122311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home