Healthcare Provider Details

I. General information

NPI: 1003367053
Provider Name (Legal Business Name): THE VILLAGE ON CAMPBELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S CAMPBELL ST
BURGAW NC
28425-5011
US

IV. Provider business mailing address

311 S CAMPBELL ST
BURGAW NC
28425-5011
US

V. Phone/Fax

Practice location:
  • Phone: 910-259-6007
  • Fax: 910-259-6111
Mailing address:
  • Phone: 910-259-6007
  • Fax: 910-259-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0461
License Number StateNC

VIII. Authorized Official

Name: MR. HUGH BLAINE CAMPBELL III
Title or Position: MANAGER
Credential:
Phone: 910-332-4508