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General NPI Number Information
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NPI Number | 1720313976
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Entity Type | Organization
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Legal Business Name | AURORA OF STATESVILLE, LLC
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Dates
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Enumeration Date | 10/06/2009
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Last Update Date | 11/17/2009
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Provider Practice Location Address
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Address Line | 1902 ORA DR
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City | STATESVILLE
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State | NC
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Zip | 28625-6343
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Country | US
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Telephone | 704-878-6376
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Fax | 704-878-6787
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Provider Business Mailing Address
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Address Line | 842 W 4TH ST
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City | WINSTON SALEM
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State | NC
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Zip | 27101-2502
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Country | US
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Telephone | 336-722-8012
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Fax | 336-722-8063
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Authorized Official
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Title or Position | MEMBER MANAGER
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Name | BRENDA K PETERSON
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Credential |
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Telephone | 704-502-3210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | HAL049028
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License Number State | NC
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