Provider Demographics
NPI:1992025316
Name:MILDRED BLACKWELL
Entity Type:Organization
Organization Name:MILDRED BLACKWELL
Other - Org Name:DOGWOOD FOREST FAMILY CARE TWO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-421-0646
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:336-421-0646
Mailing Address - Fax:336-599-4349
Practice Address - Street 1:3592 MARSHALL GRAVES RD
Practice Address - Street 2:
Practice Address - City:YANCEYVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379-8630
Practice Address - Country:US
Practice Address - Phone:336-421-0646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home