Basic Information
| Provider Information | |||||||||
| NPI: | 1285270876 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EC OPCO SOUTHPORT LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | ELMCROFT OF SOUTHPORT | ||||||||
| Address2: | 5885 MEADOWS ROAD #500 | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712134234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1125 E LEONARD ST | ||||||||
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| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284618316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104544001 | ||||||||
| FaxNumber: | 9104540300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2019 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | FLEMING | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER FOR MANAGEMENT COMPANY | ||||||||
| AuthorizedOfficialTelephone: | 9712273922 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.