Provider Demographics
NPI:1295114098
Name:MCDANIEL HOMES, LLC
Entity type:Organization
Organization Name:MCDANIEL HOMES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS-MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:339-599-1073
Mailing Address - Street 1:PO BOX1636
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27574
Mailing Address - Country:US
Mailing Address - Phone:336-599-1073
Mailing Address - Fax:336-599-8186
Practice Address - Street 1:4694 CHUBB LAKE ROAD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27574
Practice Address - Country:US
Practice Address - Phone:336-599-1073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCDANIEL HOMES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 261QD1600X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053571299Medicaid
NC1710326079Medicaid
NC1144669409Medicaid