Basic Information
Provider Information | |||||||||
NPI: | 1073689402 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BCC NORTH RIDGE OPERATIONS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9510 ORMSBY STATION RD | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402234081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5027536004 | ||||||||
FaxNumber: | 5027536104 | ||||||||
Practice Location | |||||||||
Address1: | 600 NEWTON RD | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276156214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198484906 | ||||||||
FaxNumber: | 9198483664 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARBER | ||||||||
AuthorizedOfficialFirstName: | ROBIN | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5027536004 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-092-124 | NC | X |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 311500000X | HAL-092-124 | NC | X |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   |
No ID Information.