Provider Demographics
NPI:1871642413
Name:WILLIE EVANS
Entity Type:Organization
Organization Name:WILLIE EVANS
Other - Org Name:WHITE STORE FAMILY CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-296-5162
Mailing Address - Street 1:2101 WHITE STORE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-8733
Mailing Address - Country:US
Mailing Address - Phone:704-292-5162
Mailing Address - Fax:704-282-4142
Practice Address - Street 1:2101 WHITE STORE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-8733
Practice Address - Country:US
Practice Address - Phone:704-292-5162
Practice Address - Fax:704-282-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL090012261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802668Medicaid