Basic Information
Provider Information | |||||||||
NPI: | 1841697422 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORNELIA NIXON DAVIS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DAVIS HEALTH AND WELLNESS AT CAMBRIDGE VILLAGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1011 PORTERS NECK RD | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284119196 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9103192111 | ||||||||
FaxNumber: | 9106867592 | ||||||||
Practice Location | |||||||||
Address1: | 83 CAVALIER DR. | ||||||||
Address2: | 200 | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284054444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9103192111 | ||||||||
FaxNumber: | 9106867592 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/26/2014 | ||||||||
LastUpdateDate: | 09/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONG | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | ALLEN | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR (CEO) | ||||||||
AuthorizedOfficialTelephone: | 9106867195 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CORNELIA NIXON DAVIS, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0645 | NC | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 3405568 | 05 | NC |   | MEDICAID |