Provider Demographics
NPI:1891815593
Name:MAE CORBETT CONNALLY
Entity Type:Organization
Organization Name:MAE CORBETT CONNALLY
Other - Org Name:CORBETT FCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAE
Authorized Official - Middle Name:CORBETT
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-234-7502
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:336-234-7502
Mailing Address - Fax:
Practice Address - Street 1:362 HUDSON RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:NC
Practice Address - Zip Code:27305-9680
Practice Address - Country:US
Practice Address - Phone:336-234-7502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL017003311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802646Medicaid