Provider Demographics
NPI:1952464968
Name:TIFFANY FAMILY CARE HOME
Entity Type:Organization
Organization Name:TIFFANY FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GODWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-373-1285
Mailing Address - Street 1:1014 HOMELAND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-7015
Mailing Address - Country:US
Mailing Address - Phone:336-373-1285
Mailing Address - Fax:336-373-1192
Practice Address - Street 1:702 MCPHEARSON STREET
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405
Practice Address - Country:US
Practice Address - Phone:336-333-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-684322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603615Medicaid