Healthcare Provider Details

I. General information

NPI: 1396399531
Provider Name (Legal Business Name): CITIZENS SENIOR LIVING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 CENTERVIEW DR STE 200
RALEIGH NC
27606-3386
US

IV. Provider business mailing address

4012 BURLINGTON MILLS RD APT 2B
WAKE FOREST NC
27587-9103
US

V. Phone/Fax

Practice location:
  • Phone: 919-276-4602
  • Fax:
Mailing address:
  • Phone: 919-633-9397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DANIEL ARCHIBONG JACK
Title or Position: CEO/ADMINISTRATOR
Credential: CEO
Phone: 919-633-9397