Provider Demographics
NPI:1790919181
Name:COMMUNITY CONNECTIONS FAMILY LIFE CENTER, LLC
Entity Type:Organization
Organization Name:COMMUNITY CONNECTIONS FAMILY LIFE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LETONYA
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-884-1519
Mailing Address - Street 1:PO BOX 9238
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27429-0238
Mailing Address - Country:US
Mailing Address - Phone:336-884-1519
Mailing Address - Fax:336-884-1519
Practice Address - Street 1:9635 SOUTHERN PINE BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-5558
Practice Address - Country:US
Practice Address - Phone:336-884-1519
Practice Address - Fax:336-884-1519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health