MEDICARE: BLADENBORO ASSISTED LIVING

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	HAL009019	NC

General Provider Information

NPI Number	:	1538356175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLADENBORO ASSISTED LIVING

Provider Business Mailing Address
First Line	:	714 E BLADEN STREET
Second Line	:
City	:	BLADENBORO
State	:	NC
Zip	:	28320-0669
Country	:	US
Telephone Number	:
Fax Number	:	910-863-2280

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	:	ADMINISTRATOR
Name	:	MS. ANN DAY
Credential	:	CEO
Telephone Number	:	910-863-3922

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	09/27/2007

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