MEDICARE: ST.MARYS ASSITED LIVING FACILITY

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	HAL078-052	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801916796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST.MARYS ASSITED LIVING FACILITY

Provider Business Mailing Address
First Line	:	PO BOX 706
Second Line	:
City	:	RED SPRINGS
State	:	NC
Zip	:	28377-0706
Country	:	US
Telephone Number	:	910-843-5461
Fax Number	:	910-843-2978

Provider Business Practice Location Address
First Line	:	104 HOPE LANE
Second Line	:
City	:	RED SPRINGS
State	:	NC
Zip	:	28377-9999
Country	:	US
Telephone Number	:	910-843-5461
Fax Number	:	910-843-2978

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. KAREN RENA BENNETT
Credential	:
Telephone Number	:	910-843-5461

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	08/22/2020

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