Basic Information
| Provider Information | |||||||||
| NPI: | 1174608541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDENTON PRIME TIME RETIREMENT VILLAGE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1487 | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272851487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365951075 | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 MARK DR | ||||||||
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| City: | EDENTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279321756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524824491 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | GUY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3365951075 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-021-005 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7804339 | 05 | NC | MEDICAID |