Healthcare Provider Details

I. General information

NPI: 1396232195
Provider Name (Legal Business Name): SOUTHERN LIVING FOR SENIORS OF BURNSVILLE NC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 LOVE FOX RD
BURNSVILLE NC
28714-9109
US

IV. Provider business mailing address

270 LOVE FOX RD
BURNSVILLE NC
28714-9109
US

V. Phone/Fax

Practice location:
  • Phone: 828-682-3417
  • Fax:
Mailing address:
  • Phone: 828-682-3417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: KENNETH SIMONS
Title or Position: MANAGING MEMBER
Credential:
Phone: 470-551-2006