Healthcare Provider Details

I. General information

NPI: 1114082419
Provider Name (Legal Business Name): NCAL- MOCKVILLE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 KEN DWIGGINS DR
MOCKSVILLE NC
27028-2439
US

IV. Provider business mailing address

1105 BROOKSTOWN AVE
WINSTON SALEM NC
27101-2524
US

V. Phone/Fax

Practice location:
  • Phone: 336-751-1209
  • Fax: 336-751-0601
Mailing address:
  • Phone: 336-724-1000
  • Fax: 336-724-9955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL-030-004
License Number StateNC

VIII. Authorized Official

Name: WILLIAM BENTON
Title or Position: CEO
Credential:
Phone: 336-724-1000