MEDICARE: ELIZABETHAN GARDENS ASSISTED LIVING CENTER INC.

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	310400000X	Assisted Living Facility	HAL090001	NC

General Provider Information

NPI Number	:	1326196528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELIZABETHAN GARDENS ASSISTED LIVING CENTER INC.

Provider Business Mailing Address
First Line	:	1812 NEW TOWN RD
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-9574
Country	:	US
Telephone Number	:	704-283-6992
Fax Number	:	704-291-7062

Provider Business Practice Location Address
First Line	:	1812 NEW TOWN RD
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-9574
Country	:	US
Telephone Number	:	704-283-6992
Fax Number	:	704-291-7062

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JIMMY FRANKLIN MOORE
Credential	:
Telephone Number	:	704-283-6992

Provider Enumeration Date	:	01/07/2007
Last Update Date	:	08/22/2020

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