Provider Demographics
NPI:1508246331
Name:MALLARD CREEK LEARNING CENTER
Entity Type:Organization
Organization Name:MALLARD CREEK LEARNING CENTER
Other - Org Name:DIVINE HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-533-2870
Mailing Address - Street 1:8136 BROWNE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1101
Mailing Address - Country:US
Mailing Address - Phone:704-533-2870
Mailing Address - Fax:
Practice Address - Street 1:8136 BROWNE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1101
Practice Address - Country:US
Practice Address - Phone:704-533-2870
Practice Address - Fax:704-948-2047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MALLARD CREEK LEARNING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-06
Last Update Date:2015-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251C00000X, 251G00000X, 251J00000X, 251K00000X, 251S00000X, 252Y00000X, 253J00000X, 253Z00000X
NC60002874251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251G00000XAgenciesHospice Care, Community Based
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC60002874OtherCHILD CARE LICENSE