MEDICARE: CCJ ADULT CARE III 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	311ZA0620X	Adult Care Home Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	FCL-023-055	OTHER	NC	FAMILY CARE HOME

General Provider Information

NPI Number	:	1215604822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCJ ADULT CARE III LLC

Provider Business Mailing Address
First Line	:	PO BOX 74
Second Line	:
City	:	BESSEMER CITY
State	:	NC
Zip	:	28016-0074
Country	:	US
Telephone Number	:	980-295-3020
Fax Number	:

Provider Business Practice Location Address
First Line	:	1833 STONEY POINT RD
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28150-9601
Country	:	US
Telephone Number	:	980-295-3020
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR/OPERATOR
Name	:	BERNICE R HOSCH
Credential	:
Telephone Number	:	980-295-3020

Provider Enumeration Date	:	08/23/2021
Last Update Date	:	09/15/2021

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