MEDICARE: ENTERPRISE HEALTHCARE OF STATESVILLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	HAL-049-015	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417071457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENTERPRISE HEALTHCARE OF STATESVILLE

Provider Business Mailing Address
First Line	:	PO BOX 1678
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-1678
Country	:	US
Telephone Number	:	336-998-5001
Fax Number	:	336-998-5470

Provider Business Practice Location Address
First Line	:	1942 VAN HAVEN DR
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28625-4365
Country	:	US
Telephone Number	:	704-878-0046
Fax Number	:	704-878-9757

Authorized Official
Title or Position	:	CONTROLLER
Name	:	EDWARD ELLER
Credential	:
Telephone Number	:	336-998-5001

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	08/22/2020

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Directions to “ENTERPRISE HEALTHCARE OF STATESVILLE ” Practice Location

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