Provider Demographics
NPI:1922123892
Name:GARVIN, EMMA LUCILLE (ADMINISTRATOR)
Entity Type:Individual
Prefix:MRS
First Name:EMMA
Middle Name:LUCILLE
Last Name:GARVIN
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1161 EDENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6114
Mailing Address - Country:US
Mailing Address - Phone:336-682-5870
Mailing Address - Fax:336-724-9674
Practice Address - Street 1:4527 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3517
Practice Address - Country:US
Practice Address - Phone:336-765-8460
Practice Address - Fax:336-724-9674
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 034-190310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805234Medicaid