Healthcare Provider Details

I. General information

NPI: 1215145966
Provider Name (Legal Business Name): CARILLON ASSISTED LIVING OF SOUTHPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 E LEONARD ST
SOUTHPORT NC
28461-8316
US

IV. Provider business mailing address

4901 WATERS EDGE DR STE. 200
RALEIGH NC
27606-2464
US

V. Phone/Fax

Practice location:
  • Phone: 910-454-4001
  • Fax: 910-454-0300
Mailing address:
  • Phone: 919-852-4000
  • Fax: 919-852-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License NumberHAL-068-023
License Number StateNC

VIII. Authorized Official

Name: MRS. EVIE G. MADERIOS
Title or Position: ACCOUNTS RECEIVABLE MANAGER
Credential:
Phone: 919-852-4000