Healthcare Provider Details

I. General information

NPI: 1861518334
Provider Name (Legal Business Name): EXTENDED CARE OF THE TRIAD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 TRINDALE RD # A STE 203
ARCHDALE NC
27263-3800
US

IV. Provider business mailing address

313 A TRINDALE RD STE 203
ARCHDALE NC
27263
US

V. Phone/Fax

Practice location:
  • Phone: 336-861-6826
  • Fax:
Mailing address:
  • Phone: 336-861-6826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIM LEA BASS
Title or Position: OWNER PRESIDENT
Credential: CNA
Phone: 336-687-9220