Healthcare Provider Details

I. General information

NPI: 1538440086
Provider Name (Legal Business Name): WEST WINDS ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 GOINS RD
PEMBROKE NC
28372-8347
US

IV. Provider business mailing address

PO BOX 3458
PEMBROKE NC
28372-3458
US

V. Phone/Fax

Practice location:
  • Phone: 910-521-0853
  • Fax: 910-521-5755
Mailing address:
  • Phone: 910-521-0853
  • Fax: 910-521-5755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberFCL-078-086
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberFCL-078-086
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberFCL-078-086
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-078-086
License Number StateNC

VIII. Authorized Official

Name: MS. KIMBERLY JACOBS
Title or Position: OWNER
Credential:
Phone: 910-442-5660