Basic Information
| Provider Information | |||||||||
| NPI: | 1215066147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINA CARE CENTER OF CHERRYVILLE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 HARRILSON RD | ||||||||
| Address2: | |||||||||
| City: | CHERRYVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280219541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044354161 | ||||||||
| FaxNumber: | 7044358979 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 HARRILSON RD | ||||||||
| Address2: | |||||||||
| City: | CHERRYVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280219541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044354161 | ||||||||
| FaxNumber: | 7044358979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEAM | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
| AuthorizedOfficialMiddleName: | BEAM | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7044354161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0287 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1084030001 | 01 | NC | MEDICARE NSC NUMBER | OTHER | 3405255 | 05 | NC | MEDICAID |