Provider Demographics
NPI:1275968679
Name:HUMPHREY FAMILY CARE HOME
Entity Type:Organization
Organization Name:HUMPHREY FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:336-448-0096
Mailing Address - Street 1:1156 HORSESHOE TRL
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:VA
Mailing Address - Zip Code:24520-3084
Mailing Address - Country:US
Mailing Address - Phone:973-868-2690
Mailing Address - Fax:434-575-5696
Practice Address - Street 1:3814 CHERRY GROVE RD
Practice Address - Street 2:
Practice Address - City:ELON
Practice Address - State:NC
Practice Address - Zip Code:27244-9485
Practice Address - Country:US
Practice Address - Phone:336-421-3001
Practice Address - Fax:336-421-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-017-032311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home