=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962479840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRC OF SALISBURY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2006
-----------------------------------------------------
Last Update Date | 07/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1404 S SALISBURY AVE
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28159-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-633-3892
-----------------------------------------------------
Fax | 704-637-2784
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28159-0005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-633-3892
-----------------------------------------------------
Fax | 704-637-2784
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. NICK ELLEDGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-679-8852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | HAL-080-009
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------