Healthcare Provider Details

I. General information

NPI: 1699698514
Provider Name (Legal Business Name): COUNTRY CLUB II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 COLTRANE MILL RD
RANDLEMAN NC
27317-8020
US

IV. Provider business mailing address

1339 COLTRANE MILL RD
RANDLEMAN NC
27317-8020
US

V. Phone/Fax

Practice location:
  • Phone: 336-312-2101
  • Fax: 336-674-1692
Mailing address:
  • Phone: 336-312-2101
  • Fax: 336-674-1692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: PEARLIE BULLOCK
Title or Position: ADMINISTRATOR
Credential:
Phone: 336-312-2101