Basic Information
| Provider Information | |||||||||
| NPI: | 1083779383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NCAL - ROCKY MOUNT, INC. | ||||||||
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| OtherOrganizationName: | SOMERSERT COURT OF ROCKY MOUNT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1105 BROOKSTOWN AVE | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271012524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367241000 | ||||||||
| FaxNumber: | 3367249955 | ||||||||
| Practice Location | |||||||||
| Address1: | 918 WESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278032532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524435592 | ||||||||
| FaxNumber: | 2524466969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 11/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | BENTON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3367241000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | HAL-064-010 | NC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 7804017 | 05 | NC | MEDICAID |