1972634905 NPI number — KERNER RIDGE ASSISTED LIVING LLC

Table of content: TIFFANY SPOONER RD, LD, CSG (NPI 1649711078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972634905 NPI number — KERNER RIDGE ASSISTED LIVING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KERNER RIDGE 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:
1972634905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
853 OLD WINSTON RD STE 118
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERNERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27284-8781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-993-7555
Provider Business Mailing Address Fax Number:
336-993-6111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 HOPKINS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERNERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27284-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-993-1881
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEAGLE
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
VP FINANCE
Authorized Official Telephone Number:
336-993-7555

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)

  • Identifier: 7804126 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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