Healthcare Provider Details

I. General information

NPI: 1770964702
Provider Name (Legal Business Name): MEBANE RIDGE ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1999 S NC HIGHWAY 119
MEBANE NC
27302-9738
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 336-993-7555
  • Fax:
Mailing address:
  • Phone: 336-993-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL001159
License Number StateNC

VIII. Authorized Official

Name: ANN WELDON
Title or Position: AR
Credential:
Phone: 336-993-7555