Provider Demographics
NPI:1033328083
Name:THE CREST OF CLEMMONS
Entity Type:Organization
Organization Name:THE CREST OF CLEMMONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PANDORA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-766-8050
Mailing Address - Street 1:6010 MEADOWBROOK MALL CT
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9266
Mailing Address - Country:US
Mailing Address - Phone:336-766-8050
Mailing Address - Fax:336-766-8054
Practice Address - Street 1:6010 MEADOWBROOK MALL CT
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9266
Practice Address - Country:US
Practice Address - Phone:336-766-8050
Practice Address - Fax:336-766-8054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-034-082310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805776Medicaid