Provider Demographics
NPI:1689794323
Name:TAMELA BLACKWELL
Entity Type:Organization
Organization Name:TAMELA BLACKWELL
Other - Org Name:DOGWOOD FOREST FAMILY CARE HOME TWO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-421-8880
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:336-421-8880
Mailing Address - Fax:
Practice Address - Street 1:3592 MARSHALL GRAVES RD
Practice Address - Street 2:
Practice Address - City:YANCEYVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379-8630
Practice Address - Country:US
Practice Address - Phone:336-421-8880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL017006311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803662Medicaid