Healthcare Provider Details

I. General information

NPI: 1609233295
Provider Name (Legal Business Name): MODERATE LIVING FOR THE AGING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ROOSEVELT ST
MOUNT GILEAD NC
27306-9606
US

IV. Provider business mailing address

PO BOX 1312
MOUNT GILEAD NC
27306-1312
US

V. Phone/Fax

Practice location:
  • Phone: 910-439-1635
  • Fax:
Mailing address:
  • Phone: 910-439-1669
  • Fax: 888-351-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number90368
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number902768
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: MS. MYSTERY E WILLIS
Title or Position: CEO
Credential:
Phone: 910-439-1669