MEDICARE: GOLDSBORO ASSISTED LIVING,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311500000X	Alzheimer Center (Dementia Center)	HAL096031	NC
2	310400000X	Assisted Living Facility	HAL096031	NC

General Provider Information

NPI Number	:	1184814600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDSBORO ASSISTED LIVING,LLC

Provider Business Mailing Address
First Line	:	2201 ROYALL AVE
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-7409
Country	:	US
Telephone Number	:	919-735-7684
Fax Number	:	919-735-8552

Provider Business Practice Location Address
First Line	:	2201 ROYALL AVE
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-7409
Country	:	US
Telephone Number	:	919-735-7684
Fax Number	:	919-735-8552

Authorized Official
Title or Position	:	CEO
Name	:	MS. ANN DAY
Credential	:
Telephone Number	:	919-922-0124

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	07/31/2007

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