Healthcare Provider Details

I. General information

NPI: 1982724100
Provider Name (Legal Business Name): SOUTHPARK SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 RUNNYMEDE LN
CHARLOTTE NC
28209-3316
US

IV. Provider business mailing address

PO BOX 3006
SALEM OR
97302-0006
US

V. Phone/Fax

Practice location:
  • Phone: 704-525-5508
  • Fax: 704-525-2672
Mailing address:
  • Phone: 503-375-9016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL060076
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberHAL060076
License Number StateNC

VIII. Authorized Official

Name: MR. JON M HARDER
Title or Position: MANAGER
Credential:
Phone: 503-375-9016