Provider Demographics
NPI:1013008234
Name:CEMMONS VILLAGE I, LLC
Entity Type:Organization
Organization Name:CEMMONS VILLAGE I, LLC
Other - Org Name:CLEMMONS VILLAGE I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-296-3985
Mailing Address - Street 1:6401 HOLDER RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9207
Mailing Address - Country:US
Mailing Address - Phone:336-766-2990
Mailing Address - Fax:336-766-2138
Practice Address - Street 1:6401 HOLDER RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9207
Practice Address - Country:US
Practice Address - Phone:336-766-2990
Practice Address - Fax:336-766-2138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-034-090310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805214Medicaid