Basic Information
| Provider Information | |||||||||
| NPI: | 1114063559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRST ASSEMBLY LIVING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 WARREN C COLEMAN BLVD N | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280276786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047934760 | ||||||||
| FaxNumber: | 7047934764 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 WARREN C COLEMAN BLVD N | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280276786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047934760 | ||||||||
| FaxNumber: | 7047934764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | HAZEL | ||||||||
| AuthorizedOfficialMiddleName: | MCCLURE | ||||||||
| AuthorizedOfficialTitleorPosition: | PCS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7047934760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-013-000 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7801009 | 05 | NC | MEDICAID |