Provider Demographics
NPI:1184174690
Name:COLLINS, EBERE
Entity type:Individual
Prefix:
First Name:EBERE
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 TREVI FOUNTAIN PL
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5928
Mailing Address - Country:US
Mailing Address - Phone:919-271-0917
Mailing Address - Fax:919-896-8233
Practice Address - Street 1:2305 GLASCOCK ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1601
Practice Address - Country:US
Practice Address - Phone:919-896-8233
Practice Address - Fax:919-896-8233
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-092-221311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home