Provider Demographics
NPI:1750501698
Name:PULLIAM FAMILY CARE HOME
Entity Type:Organization
Organization Name:PULLIAM FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-449-5418
Mailing Address - Street 1:809 W MINNEOLA ST
Mailing Address - Street 2:
Mailing Address - City:GIBSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27249-8880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:809 W MINNEOLA ST
Practice Address - Street 2:
Practice Address - City:GIBSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27249-8880
Practice Address - Country:US
Practice Address - Phone:336-449-5418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC041-031311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801204Medicaid