Basic Information
| Provider Information | |||||||||
| NPI: | 1891830519 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BENEATH THE TREES DBA CORINTHIAN PLACE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORINTHIAN PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1935 LINCOLN ROAD | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284519187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103836235 | ||||||||
| FaxNumber: | 9103836248 | ||||||||
| Practice Location | |||||||||
| Address1: | 1935 LINCOLN ROAD | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284519187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103836235 | ||||||||
| FaxNumber: | 9103836248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9103836235 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | HAL010006 | NC | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | HAL010006 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7805476 | 05 | NC | MEDICAID |