Basic Information
| Provider Information | |||||||||
| NPI: | 1568670206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARILLON ASSISTED LIVING OF HENDERSONVILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 WATERS EDGE DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276062464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198524000 | ||||||||
| FaxNumber: | 9198524001 | ||||||||
| Practice Location | |||||||||
| Address1: | 3851 HOWARD GAP RD | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287923102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286930700 | ||||||||
| FaxNumber: | 8286970027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MADERIOS | ||||||||
| AuthorizedOfficialFirstName: | EVIE | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTS RECEIVABLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9198524000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 177F00000X | HAL-045-093 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Lodging |
ID Information
| ID | Type | State | Issuer | Description | 7805403 | 05 | NC | MEDICAID |