1710269121 NPI number — TANGLEWOOD ASSISTED LIVING LLC

Table of content: (NPI 1710269121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710269121 NPI number — TANGLEWOOD ASSISTED LIVING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TANGLEWOOD ASSISTED LIVING 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:
1710269121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 847
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28433-0847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-648-6887
Provider Business Mailing Address Fax Number:
910-648-6888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1437 AVERSBORO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARNER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27529-4546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-779-4560
Provider Business Practice Location Address Fax Number:
919-779-1035
Provider Enumeration Date:
09/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
RILEY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
910-648-6887

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  HAL-092-170 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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