Healthcare Provider Details

I. General information

NPI: 1275371015
Provider Name (Legal Business Name): SUPPORTIVE SPACES ADULT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MORGAN DR
ZEBULON NC
27597-5959
US

IV. Provider business mailing address

1513 PARKS VILLAGE RD
ZEBULON NC
27597-9580
US

V. Phone/Fax

Practice location:
  • Phone: 919-671-1989
  • Fax:
Mailing address:
  • Phone: 919-671-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DESHON WISE
Title or Position: DIRECTOR
Credential:
Phone: 919-671-1989