Provider Demographics
NPI:1952560997
Name:ETTALOVE FAMILY CARE HOME
Entity Type:Organization
Organization Name:ETTALOVE FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-509-5596
Mailing Address - Street 1:1951 DIETRICH LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-3526
Mailing Address - Country:US
Mailing Address - Phone:704-509-5596
Mailing Address - Fax:704-509-5596
Practice Address - Street 1:1951 DIETRICH LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3526
Practice Address - Country:US
Practice Address - Phone:704-509-5596
Practice Address - Fax:704-509-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-060-072261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805172Medicaid