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General NPI Number Information
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NPI Number | 1417071457
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Entity Type | Organization
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Legal Business Name | ENTERPRISE HEALTHCARE OF STATESVILLE
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1942 VAN HAVEN DR
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City | STATESVILLE
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State | NC
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Zip | 28625-4365
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Country | US
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Telephone | 704-878-0046
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Fax | 704-878-9757
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Provider Business Mailing Address
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Address Line | PO BOX 1678
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City | CLEMMONS
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State | NC
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Zip | 27012-1678
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Country | US
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Telephone | 336-998-5001
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Fax | 336-998-5470
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Authorized Official
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Title or Position | CONTROLLER
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Name | EDWARD ELLER
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Credential |
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Telephone | 336-998-5001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | HAL-049-015
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License Number State | NC
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