Provider Demographics
NPI:1548421506
Name:WADIN CREEK FAMILY CARE HOME
Entity Type:Organization
Organization Name:WADIN CREEK FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-728-6525
Mailing Address - Street 1:819 HWY 101
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:NC
Mailing Address - Zip Code:28516-7718
Mailing Address - Country:US
Mailing Address - Phone:252-728-6525
Mailing Address - Fax:252-728-2801
Practice Address - Street 1:819 HWY 101
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:NC
Practice Address - Zip Code:28516-7718
Practice Address - Country:US
Practice Address - Phone:252-728-6525
Practice Address - Fax:252-728-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL016-005311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC78011816Medicaid