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General NPI Number Information
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NPI Number | 1770811804
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Entity Type | Organization
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Legal Business Name | AVALON # 4
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Dates
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Enumeration Date | 12/01/2009
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Last Update Date | 12/01/2009
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Provider Practice Location Address
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Address Line | 5040 KAPLAN DR
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City | RALEIGH
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State | NC
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Zip | 27606-2523
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Country | US
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Telephone | 336-253-2219
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Fax |
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Provider Business Mailing Address
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Address Line | 4428 LOUISBURG RD SUITE 109
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City | RALEIGH
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State | NC
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Zip | 27616-4302
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Country | US
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Telephone | 336-253-2219
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | IJEOMA NWANKWO
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Credential |
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Telephone | 336-253-2219
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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 |
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License Number State |
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