Basic Information
| Provider Information | |||||||||
| NPI: | 1790001246 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDENTON RETIREMENT COMMUNITY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 814 | ||||||||
| Address2: | |||||||||
| City: | RANDLEMAN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273170814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364952700 | ||||||||
| FaxNumber: | 3364955552 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 MARK DR | ||||||||
| Address2: | |||||||||
| City: | EDENTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279321756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524824491 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2010 | ||||||||
| LastUpdateDate: | 06/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3364952700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | HAL-021-008 | NC | N | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7806302 | 05 | NC | MEDICAID |