Healthcare Provider Details

I. General information

NPI: 1689818221
Provider Name (Legal Business Name): THE VILLAGE OF KINSTON ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 IDLEWILD DR
KINSTON NC
28504-7148
US

IV. Provider business mailing address

PO BOX 814
RANDLEMAN NC
27317-0814
US

V. Phone/Fax

Practice location:
  • Phone: 252-208-7103
  • Fax:
Mailing address:
  • Phone: 336-495-2700
  • Fax: 336-495-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL-054-067
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

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