Provider Demographics
NPI:1417002445
Name:CLASSIC CARE HOMES
Entity Type:Organization
Organization Name:CLASSIC CARE HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-934-8976
Mailing Address - Street 1:101 ANNIE PARKER CIR
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-3968
Mailing Address - Country:US
Mailing Address - Phone:919-934-8976
Mailing Address - Fax:919-934-8976
Practice Address - Street 1:101 ANNIE PARKER CIR
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-3968
Practice Address - Country:US
Practice Address - Phone:919-934-8976
Practice Address - Fax:919-934-8976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-051-018310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801454Medicaid