Healthcare Provider Details

I. General information

NPI: 1285285601
Provider Name (Legal Business Name): GAHC3 CLEMMONS NC TRS SUB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 S PEACE HAVEN RD
CLEMMONS NC
27012-8910
US

IV. Provider business mailing address

18191 VON KARMAN AVE STE 300
IRVINE CA
92612-7106
US

V. Phone/Fax

Practice location:
  • Phone: 336-766-6220
  • Fax: 336-766-7613
Mailing address:
  • Phone: 949-270-9200
  • Fax: 949-474-0442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: DANNY PROSKY
Title or Position: PRESIDENT
Credential:
Phone: 949-270-9200