Basic Information
Provider Information | |||||||||
NPI: | 1548478274 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARILLON ASSISTED LIVING OF NEWTON | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4901 WATERS EDGE DR | ||||||||
Address2: | STE. 200 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276062464 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198524000 | ||||||||
FaxNumber: | 9198524001 | ||||||||
Practice Location | |||||||||
Address1: | 1088 RADIO STATION RD | ||||||||
Address2: |   | ||||||||
City: | NEWTON | ||||||||
State: | NC | ||||||||
PostalCode: | 286589478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8284667474 | ||||||||
FaxNumber: | 8284667477 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MADERIOS | ||||||||
AuthorizedOfficialFirstName: | EVIE | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | ACCOUNTS RECEIVABLE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9198524000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 177F00000X | HAL-018-017 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Lodging |   |
ID Information
ID | Type | State | Issuer | Description | 7804096 | 05 | NC |   | MEDICAID |