Provider Demographics
NPI:1457405375
Name:MOORE'S FAMILY CARE HOME 1
Entity Type:Organization
Organization Name:MOORE'S FAMILY CARE HOME 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AVA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE-DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-356-2197
Mailing Address - Street 1:231 MORRIS FORD RD
Mailing Address - Street 2:
Mailing Address - City:COLERAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27924-9172
Mailing Address - Country:US
Mailing Address - Phone:252-356-2197
Mailing Address - Fax:252-356-4527
Practice Address - Street 1:231 MORRIS FORD RD
Practice Address - Street 2:
Practice Address - City:COLERAIN
Practice Address - State:NC
Practice Address - Zip Code:27924-9172
Practice Address - Country:US
Practice Address - Phone:252-356-2197
Practice Address - Fax:252-356-4527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-008-016320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804790Medicaid