Healthcare Provider Details

I. General information

NPI: 1457471948
Provider Name (Legal Business Name): CAGLES REST HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DOVER RD
STAR NC
27356-7772
US

IV. Provider business mailing address

601 DOVER RD PO BOX 400
STAR NC
27356-7772
US

V. Phone/Fax

Practice location:
  • Phone: 910-428-4350
  • Fax: 910-428-4376
Mailing address:
  • Phone: 910-428-4350
  • Fax: 910-428-4376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License NumberHAL062003
License Number StateNC

VIII. Authorized Official

Name: MS. PATRICIA A CAGLE
Title or Position: OWNER
Credential:
Phone: 910-428-4350