Provider Demographics
NPI:1659596575
Name:ELLISON'S FAMILY CARE HOME3
Entity Type:Organization
Organization Name:ELLISON'S FAMILY CARE HOME3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:B
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-349-2220
Mailing Address - Street 1:PO BOX 1316
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323-1316
Mailing Address - Country:US
Mailing Address - Phone:336-349-2220
Mailing Address - Fax:336-349-2273
Practice Address - Street 1:31 ALEX POTEAT RD
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-9741
Practice Address - Country:US
Practice Address - Phone:336-634-1332
Practice Address - Fax:336-349-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-017-029310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803270Medicaid