=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740558675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARBOR CARE ASSISTED LIVING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2011
-----------------------------------------------------
Last Update Date | 12/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 BANNER AVE
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-273-2380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 999
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28758-0999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-676-9063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES/ CEO/ ADMINISTRATOR
-----------------------------------------------------
Name | MR. ROBERT G CRUMMIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-676-9063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | HAL 041075
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------