MEDICARE: M&T ENHANCEMENT RESIDENTIAL CARE, 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	310400000X	Assisted Living Facility	047-139	NC

General Provider Information

NPI Number	:	1528353133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M&T ENHANCEMENT RESIDENTIAL CARE, LLC

Provider Business Mailing Address
First Line	:	126 DAVENPORT DR
Second Line	:
City	:	RAEFORD
State	:	NC
Zip	:	28376-5425
Country	:	US
Telephone Number	:	910-848-2286
Fax Number	:	910-875-8842

Provider Business Practice Location Address
First Line	:	126 DAVENPORT DR
Second Line	:
City	:	RAEFORD
State	:	NC
Zip	:	28376-5425
Country	:	US
Telephone Number	:	910-848-2286
Fax Number	:	910-875-8842

Authorized Official
Title or Position	:	OWNER
Name	:	MICHEAUX HOLLINGSWORTH
Credential	:
Telephone Number	:	910-884-8889

Provider Enumeration Date	:	06/10/2011
Last Update Date	:	06/10/2011

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