=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770971020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BJR, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2015
-----------------------------------------------------
Last Update Date | 01/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 W. BUNCOMBE ST
-----------------------------------------------------
City | ROPER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27970-0340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-791-0002
-----------------------------------------------------
Fax | 252-791-0772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206B MALLOY ST
-----------------------------------------------------
City | GOLDSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27534-4477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-778-6974
-----------------------------------------------------
Fax | 919-778-6997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROY EXCELL MARKHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-778-6974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | HAL-094-006
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------