Basic Information
Provider Information | |||||||||
NPI: | 1134765720 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EC OPCO SHELBY LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | ELMCROFT OF SHELBY | ||||||||
Address2: | 5885 MEADOWS RD #500 | ||||||||
City: | LAKE OSWEGO | ||||||||
State: | OR | ||||||||
PostalCode: | 97035 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9712134234 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1550 CHARLES RD | ||||||||
Address2: |   | ||||||||
City: | SHELBY | ||||||||
State: | NC | ||||||||
PostalCode: | 281527036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044712828 | ||||||||
FaxNumber: | 7044712829 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2019 | ||||||||
LastUpdateDate: | 11/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLEMING | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER OF MANAGEMENT COMPANY | ||||||||
AuthorizedOfficialTelephone: | 9712273922 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X |   |   | N |   | Nursing & Custodial Care Facilities | Custodial Care Facility |   | 311ZA0620X |   |   | N |   | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.