Provider Demographics
NPI:1760709364
Name:ANT MARY'S FAMILY CARE #1
Entity Type:Organization
Organization Name:ANT MARY'S FAMILY CARE #1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EULA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-344-9903
Mailing Address - Street 1:104 WEST JAMES ST.
Mailing Address - Street 2:ANT MARY'S FAMILY CARE HOME #1
Mailing Address - City:LAGRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551-3770
Mailing Address - Country:US
Mailing Address - Phone:919-344-9903
Mailing Address - Fax:
Practice Address - Street 1:104 WEST JAMES STREET
Practice Address - Street 2:ANT MARY'S FAMILY CARE HOME #1
Practice Address - City:LAGRANGE
Practice Address - State:NC
Practice Address - Zip Code:28551-3770
Practice Address - Country:US
Practice Address - Phone:919-344-9903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL054065261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center