Provider Demographics
NPI:1497874002
Name:NELLIES FAMILY CARE HOME INC
Entity Type:Organization
Organization Name:NELLIES FAMILY CARE HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-480-1332
Mailing Address - Street 1:1608 FALLSTON RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3365
Mailing Address - Country:US
Mailing Address - Phone:704-482-0340
Mailing Address - Fax:
Practice Address - Street 1:1608 FALLSTON ROAD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4619
Practice Address - Country:US
Practice Address - Phone:704-482-0340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL 023-015310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804625Medicaid
NC7804624Medicaid