Provider Demographics
NPI:1619295615
Name:VICKY D CONNALLY
Entity Type:Organization
Organization Name:VICKY D CONNALLY
Other - Org Name:CORBETTS FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CONNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-234-7502
Mailing Address - Street 1:203 N MAIN ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-5343
Mailing Address - Country:US
Mailing Address - Phone:336-234-7502
Mailing Address - Fax:336-234-0037
Practice Address - Street 1:362 HUDSON RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:NC
Practice Address - Zip Code:27305-9680
Practice Address - Country:US
Practice Address - Phone:336-234-7502
Practice Address - Fax:336-234-0037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL017050311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home