Healthcare Provider Details

I. General information

NPI: 1386704336
Provider Name (Legal Business Name): NCAL-CHERRYVILLE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W ACADEMY ST
CHERRYVILLE NC
28021-3101
US

IV. Provider business mailing address

1105 BROOKSTOWN AVE
WINSTON SALEM NC
27101-2524
US

V. Phone/Fax

Practice location:
  • Phone: 704-445-1554
  • Fax: 704-445-1501
Mailing address:
  • Phone: 336-724-1000
  • Fax: 336-724-9955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL-036017
License Number StateNC

VIII. Authorized Official

Name: MR. WILLIAM BENTON
Title or Position: CEO
Credential:
Phone: 336-724-1000