Healthcare Provider Details

I. General information

NPI: 1053745471
Provider Name (Legal Business Name): PRIDDY MANOR ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1294 PRIDDY ROAD
KING NC
27021
US

IV. Provider business mailing address

853 OLD WINSTON RD SUITE 118
KERNERSVILLE NC
27284-7143
US

V. Phone/Fax

Practice location:
  • Phone: 336-983-3068
  • Fax: 336-995-6098
Mailing address:
  • Phone: 336-993-7555
  • Fax: 336-993-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL085009
License Number StateNC

VIII. Authorized Official

Name: MR. STEVE BAILEY
Title or Position: VP
Credential:
Phone: 336-993-7555