Basic Information
| Provider Information | |||||||||
| NPI: | 1871723791 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARILLON ASSISTED LIVING OF FAYETTEVILLE, LLC | ||||||||
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| OtherOrganizationName: | CARILLON ASSISTED LIVING OF FAYETTEVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 WATERS EDGE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276062464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198524000 | ||||||||
| FaxNumber: | 9198524001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1164 71ST SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283142817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198524000 | ||||||||
| FaxNumber: | 9198524001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9198524000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.