Healthcare Provider Details

I. General information

NPI: 1538356175
Provider Name (Legal Business Name): BLADENBORO ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 ROYALL AVE
GOLDSBORO NC
27534-7409
US

IV. Provider business mailing address

714 E BLADEN STREET
BLADENBORO NC
28320-0669
US

V. Phone/Fax

Practice location:
  • Phone: 919-735-7684
  • Fax: 919-735-8552
Mailing address:
  • Phone:
  • Fax: 910-863-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL009019
License Number StateNC

VIII. Authorized Official

Name: MS. ANN DAY
Title or Position: ADMINISTRATOR
Credential: CEO
Phone: 910-863-3922