Provider Demographics
NPI:1306357652
Name:KINGDOM FAMILY CARE HOME
Entity Type:Organization
Organization Name:KINGDOM FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEATHA
Authorized Official - Middle Name:DUNN
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:091-990-2297
Mailing Address - Street 1:11062 HWY 50 NORTH
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504
Mailing Address - Country:US
Mailing Address - Phone:919-902-2297
Mailing Address - Fax:
Practice Address - Street 1:11062 HWY 50 NORTH
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504
Practice Address - Country:US
Practice Address - Phone:919-902-2297
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care