1104944081 NPI number — FALCON CREST RESIDENTIAL CARE

Table of content: (NPI 1104944081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104944081 NPI number — FALCON CREST RESIDENTIAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FALCON CREST RESIDENTIAL CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104944081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 SOUTH FIFTH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEBANE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27302-1101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-226-2575
Provider Business Mailing Address Fax Number:
336-226-2474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 S FIFTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEBANE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27302-9182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-226-2575
Provider Business Practice Location Address Fax Number:
336-226-2474
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRADSHER
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
ADM. MANAGER/OWNER
Authorized Official Telephone Number:
336-226-2575

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  753096607 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320600000X , with the licence number: MHL-001-103 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320600000X , with the licence number: MHL-001-141 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 322D00000X , with the licence number: MHL-001-141 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 322D00000X , with the licence number: MHL-001-103 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6603770 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603998 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603415 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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