Healthcare Provider Details

I. General information

NPI: 1821929365
Provider Name (Legal Business Name): CAROLINA SUPPORTIVE LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 E MAIN ST
OLD FORT NC
28762-5768
US

IV. Provider business mailing address

1259 E MAIN ST
OLD FORT NC
28762-5768
US

V. Phone/Fax

Practice location:
  • Phone: 828-470-8642
  • Fax:
Mailing address:
  • Phone: 828-470-8642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: OMECIA MARGARRITA PONDER
Title or Position: OWNER
Credential:
Phone: 828-747-5978