Mt. Olive Family Care Home #2

Key facts

NPI: 1700914595
Entity type: Organization (NPI type 2)
Primary specialty: Adult Care Home Facility 311ZA0620X
License: FCL-078-015 (NC)
Legal business name: MT. OLIVE FAMILY CARE HOME #2
Practice address: 14471 NC Highway 41 S
Fairmont, NC 28340-5977
Phone: (910) 628-7594
NPI assigned: Mar 1, 2007
Organization subpart: No

Authorized official

Name: Mr. Willie Edward Spruill
Title: Administrator
Phone: (910) 628-7755

Corporate family (same tax ID) 1

Organizations that report the same tax identification number in the National Provider Directory.

Mt. Olive Family Care Home Adult Care Home Facility · Whiteville, NC · NPI 1467580241

NPD tax ID

National Provider Directory

Tax ID family: Mt Olive Family Care Home (2 organizations share this tax ID)

Locations

14471 NC Highway 41 S
Fairmont, NC 28340
Phone (910) 628-7594

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Adult Care Home Facility	311ZA0620X	FCL-078-015	NC	Yes

Addresses

Primary practice location

14471 NC Highway 41 S
Fairmont, NC 28340-5977

Mailing address

305 Jackson St
Fairmont, NC 28340-1621
Phone (910) 628-7755

Other identifiers

Identifier	Type	State	Issuer
7801471	Medicaid	NC

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Aug 22, 2020.

{
    "created_epoch": "1172707200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1700914595",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "305 JACKSON ST",
            "city": "FAIRMONT",
            "state": "NC",
            "postal_code": "283401621",
            "telephone_number": "910-628-7755",
            "fax_number": "910-628-7755"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14471 NC HIGHWAY 41 S",
            "city": "FAIRMONT",
            "state": "NC",
            "postal_code": "283405977",
            "telephone_number": "910-628-7594"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MT. OLIVE FAMILY CARE HOME #2",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-01",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "SPRUILL",
        "authorized_official_first_name": "WILLIE",
        "authorized_official_middle_name": "EDWARD",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "910-628-7755",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "311ZA0620X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility, Adult Care Home",
            "state": "NC",
            "license": "FCL-078-015",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7801471",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fairmont, NC

All providers in Fairmont, NC · Adult Care Home Facility in North Carolina

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.