Basic Information
| Provider Information | |||||||||
| NPI: | 1114082419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NCAL- MOCKVILLE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOMERSET COURT OF MOCKSVILLE | ||||||||
| 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: | 150 KEN DWIGGINS DR | ||||||||
| Address2: | |||||||||
| City: | MOCKSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270282439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367511209 | ||||||||
| FaxNumber: | 3367510601 | ||||||||
| 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 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | HAL-030-004 | NC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 7805398 | 05 | NC | MEDICAID |