Provider Demographics
NPI:1336423540
Name:COMMUNITY CONNECTIONS FAMILY LIFE CENTER LLC
Entity Type:Organization
Organization Name:COMMUNITY CONNECTIONS FAMILY LIFE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOE
Authorized Official - Prefix:
Authorized Official - First Name:LETONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-884-7179
Mailing Address - Street 1:622 N HAMILTON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4076
Mailing Address - Country:US
Mailing Address - Phone:336-884-7179
Mailing Address - Fax:336-884-7189
Practice Address - Street 1:622 N HAMILTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4076
Practice Address - Country:US
Practice Address - Phone:336-884-7179
Practice Address - Fax:336-884-7189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8303323252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8303323Medicaid