1154078715 NPI number — ALBERTACARE, LLC

Table of content: (NPI 1154078715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154078715 NPI number — ALBERTACARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBERTACARE, 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:
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:
1154078715
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9121 ANSON WAY STE 200
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:
27615-5857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-916-7783
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 E CLUB BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27704-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-908-6480
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PULLEY
Authorized Official First Name:
TARSHIA
Authorized Official Middle Name:
MCCRAY
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
919-916-7783

Provider Taxonomy Codes

  • Taxonomy code: 320600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MHL-032-622 . This is a "FACILITY LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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