=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609494897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P&C ADULT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2020
-----------------------------------------------------
Last Update Date | 07/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1345 CHAPMAN LN
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28658-1778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-464-6490
-----------------------------------------------------
Fax | 828-466-3002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1002 BELL RIDGE CT
-----------------------------------------------------
City | ROCKWELL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28138-7437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-239-2199
-----------------------------------------------------
Fax | 704-856-8196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER MANGER/OWNER
-----------------------------------------------------
Name | MR. CASEY BLACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-239-2199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------