Basic Information
| Provider Information | |||||||||
| NPI: | 1699761718 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOREST TRAIL OF CLINTON, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | THE MAGNOLIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 213 FOREST TRL | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283283353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105927506 | ||||||||
| FaxNumber: | 9105927604 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 FOREST TRL | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283283353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105927506 | ||||||||
| FaxNumber: | 9105927604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 12/15/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALLMAN | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8283225535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL082014 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7805300 | 05 | NC | MEDICAID |