Healthcare Provider Details

I. General information

NPI: 1750402384
Provider Name (Legal Business Name): DELOATCHS REST VILLA 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E LEWISTOWN RD
MURFREESBORO NC
27855-9322
US

IV. Provider business mailing address

104 E LEWISTOWN RD
MURFREESBORO NC
27855-9322
US

V. Phone/Fax

Practice location:
  • Phone: 252-398-3662
  • Fax:
Mailing address:
  • Phone: 252-398-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. SHIRLEY DELOATCH
Title or Position: ADMINISTRATOR
Credential:
Phone: 252-398-3662