Healthcare Provider Details

I. General information

NPI: 1356744932
Provider Name (Legal Business Name): Z & M RESIDENTIAL VILLA 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10298 PASTURE RD
MIDDLESEX NC
27557-7200
US

IV. Provider business mailing address

10298 PASTURE RD
MIDDLESEX NC
27557-7200
US

V. Phone/Fax

Practice location:
  • Phone: 919-527-4856
  • Fax:
Mailing address:
  • Phone: 919-527-4856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberFCL064026
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberFCL064026
License Number StateNC

VIII. Authorized Official

Name: TIM MACK
Title or Position: DIRECTOR
Credential:
Phone: 919-527-4856