Healthcare Provider Details

I. General information

NPI: 1316087992
Provider Name (Legal Business Name): COUNTRY CLUB II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 OLD COURTHOUSE RD
SOPHIA NC
27350-8866
US

IV. Provider business mailing address

1324 COLTRANE MILL RD
RANDLEMAN NC
27317-8020
US

V. Phone/Fax

Practice location:
  • Phone: 336-674-6293
  • Fax:
Mailing address:
  • Phone: 336-674-6293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License NumberFCL076031
License Number StateNC

VIII. Authorized Official

Name: MS. PEARLIE M. BULLOCK
Title or Position: ADMINISTRATOR
Credential:
Phone: 336-674-6293