Healthcare Provider Details

I. General information

NPI: 1710538160
Provider Name (Legal Business Name): GAHC3 WAKE FOREST NC TRS SUB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3218 HERITAGE TRADE DR
WAKE FOREST NC
27587-4238
US

IV. Provider business mailing address

18191 VON KARMAN AVE STE 300
IRVINE CA
92612-7106
US

V. Phone/Fax

Practice location:
  • Phone: 919-569-2101
  • Fax: 919-569-2102
Mailing address:
  • Phone: 949-270-9200
  • Fax: 949-474-0442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: DANNY PROSKY
Title or Position: PRESIDENT
Credential:
Phone: 949-270-9200