MEDICARE: CENTURY CARE OF THE CRYSTAL COAST, INC

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	314000000X	Skilled Nursing Facility	NH0227	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0080Q	OTHER	NC	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1851375703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTURY CARE OF THE CRYSTAL COAST, INC

Provider Business Mailing Address
First Line	:	4010 BRIDGES STREET EXTENSION
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-4304
Country	:	US
Telephone Number	:	252-726-0031
Fax Number	:	252-726-5831

Provider Business Practice Location Address
First Line	:	4010 BRIDGES STREET EXTENSION
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-4304
Country	:	US
Telephone Number	:	252-726-0031
Fax Number	:	252-726-5831

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ROBERT E GILLIAM
Credential	:
Telephone Number	:	919-467-8686

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	07/08/2008

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