Provider Demographics
NPI:1275755639
Name:DYNAMIC CARE HOME
Entity Type:Organization
Organization Name:DYNAMIC CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEARLDENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-483-6416
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28302-0504
Mailing Address - Country:US
Mailing Address - Phone:910-483-6416
Mailing Address - Fax:910-483-5924
Practice Address - Street 1:739 AMBER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1886
Practice Address - Country:US
Practice Address - Phone:910-483-6416
Practice Address - Fax:910-483-5924
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESTIGE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-026-558320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603198Medicaid