Basic Information
| Provider Information | |||||||||
| NPI: | 1508134685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOVRAN SENIOR LIVING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SSL OF MOUNT OLIVE NC LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 CENTREPARK BLVD STE 810 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334017412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396594900 | ||||||||
| FaxNumber: | 2399633410 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 SMITH CHAPEL RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT OLIVE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283652632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196586501 | ||||||||
| FaxNumber: | 9196586799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2011 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | DORENE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MIS | ||||||||
| AuthorizedOfficialTelephone: | 2396594900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.