Basic Information
| Provider Information | |||||||||
| NPI: | 1366624504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRYSON CITY LIVING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 314 HUGHES BRANCH ROAD | ||||||||
| Address2: | |||||||||
| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284882780 | ||||||||
| FaxNumber: | 8284885961 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 HUGHES BRANCH ROAD | ||||||||
| Address2: | |||||||||
| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284882780 | ||||||||
| FaxNumber: | 8284885961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | HODGES | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8287383046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ADMINISTRATOR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | HAL 087 003 | NC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | HAL 087 003 | 01 | NC | LICENSE | OTHER |