MEDICARE: SANCTUARY AT LAKE DANIELS LLC

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1710854344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANCTUARY AT LAKE DANIELS LLC

Provider Business Mailing Address
First Line	:	1405 GARLAND DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27408-8609
Country	:	US
Telephone Number	:	951-391-9028
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 GARLAND DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27408-8609
Country	:	US
Telephone Number	:	951-391-9028
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CANDIS TATE
Credential	:
Telephone Number	:	951-391-9028

Provider Enumeration Date	:	10/20/2025
Last Update Date	:	10/21/2025

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