1932855400 NPI number — RSS/CLEMMONS OPERATIONS, LLC

Table of content: DR. CONNIE MAY VERHAGEN D.D.S. (NPI 1952489122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932855400 NPI number — RSS/CLEMMONS OPERATIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RSS/CLEMMONS OPERATIONS, LLC
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:
MALLARD RIDGE ASSISTED LIVING
Provider Other Organization Name Type Code:
3
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:
1932855400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5430 WADE PARK BLVD STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27607-4191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-371-4233
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9420 N NC HWY 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEMMONS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27012-6853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-895-1293
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2022

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
JENNILEE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
919-371-4233

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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