Provider Demographics
NPI:1871613299
Name:PROFESSONAL FAMILY HEALTH SERVICE
Entity type:Organization
Organization Name:PROFESSONAL FAMILY HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHALEACCA
Authorized Official - Middle Name:RESHAUN
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-398-3350
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27855-0111
Mailing Address - Country:US
Mailing Address - Phone:252-398-3350
Mailing Address - Fax:
Practice Address - Street 1:130 SPRING BRANCH RD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:NC
Practice Address - Zip Code:27855-9577
Practice Address - Country:US
Practice Address - Phone:252-398-3350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2949313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601250Medicaid