Healthcare Provider Details

I. General information

NPI: 1992793962
Provider Name (Legal Business Name): WOODBURY WELLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2778 COUNTRY CLUB DR
HAMPSTEAD NC
28443-8028
US

IV. Provider business mailing address

2778 COUNTRY CLUB DR
HAMPSTEAD NC
28443-8028
US

V. Phone/Fax

Practice location:
  • Phone: 910-270-1443
  • Fax: 910-270-1826
Mailing address:
  • Phone: 910-270-1443
  • Fax: 910-270-1826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberNH0300
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberNH0300
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0300
License Number StateNC

VIII. Authorized Official

Name: MRS. RENEE PRIDGEN
Title or Position: BUSINESS OFFICE MGR
Credential:
Phone: 910-270-1443