Healthcare Provider Details

I. General information

NPI: 1609248855
Provider Name (Legal Business Name): COUNTRY LIVING ESTATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4761 DRAUGHON RD
FAYETTEVILLE NC
28312-8480
US

IV. Provider business mailing address

4761 DRAUGHON RD
FAYETTEVILLE NC
28312-8480
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-1701
  • Fax: 910-484-1703
Mailing address:
  • Phone: 910-484-1701
  • Fax: 910-484-1703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateNC

VIII. Authorized Official

Name: HILDA MOORE
Title or Position: ADMINISTRATOR
Credential:
Phone: 910-484-1701