Healthcare Provider Details

I. General information

NPI: 1790001246
Provider Name (Legal Business Name): EDENTON RETIREMENT COMMUNITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MARK DR
EDENTON NC
27932-1756
US

IV. Provider business mailing address

PO BOX 814
RANDLEMAN NC
27317-0814
US

V. Phone/Fax

Practice location:
  • Phone: 252-482-4491
  • Fax:
Mailing address:
  • Phone: 336-495-2700
  • Fax: 336-495-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL-021-008
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID DEAN WILSON
Title or Position: MANAGING PARTNER
Credential:
Phone: 336-495-2700