Healthcare Provider Details

I. General information

NPI: 1710269121
Provider Name (Legal Business Name): TANGLEWOOD ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 AVERSBORO RD
GARNER NC
27529-4546
US

IV. Provider business mailing address

PO BOX 847
CLARKTON NC
28433-0847
US

V. Phone/Fax

Practice location:
  • Phone: 919-779-4560
  • Fax: 919-779-1035
Mailing address:
  • Phone: 910-648-6887
  • Fax: 910-648-6888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL-092-170
License Number StateNC

VIII. Authorized Official

Name: RILEY S EVANS
Title or Position: MANAGING MEMBER
Credential:
Phone: 910-648-6887