Provider Demographics
NPI:1366635120
Name:HARRIS, MILDRED (ADMINISTRATOR)
Entity Type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 HWY 101
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:NC
Mailing Address - Zip Code:28516-7717
Mailing Address - Country:US
Mailing Address - Phone:252-728-7490
Mailing Address - Fax:
Practice Address - Street 1:834 HWY 101
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:NC
Practice Address - Zip Code:28516-7717
Practice Address - Country:US
Practice Address - Phone:252-728-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL016-013311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803990Medicaid