Healthcare Provider Details

I. General information

NPI: 1669819157
Provider Name (Legal Business Name): CUMBERLAND VILLAGE ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 CEDAR CREEK RD
FAYETTEVILLE NC
28312-6544
US

IV. Provider business mailing address

PO BOX 814
RANDLEMAN NC
27317-0814
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-8212
  • Fax:
Mailing address:
  • Phone: 336-495-2723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

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