Provider Demographics
NPI:1063644748
Name:SOUTHERN LIVING ASSISTED CARE, LLC
Entity Type:Organization
Organization Name:SOUTHERN LIVING ASSISTED CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEAGAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-612-5092
Mailing Address - Street 1:PO BOX 7386
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-7386
Mailing Address - Country:US
Mailing Address - Phone:252-752-3402
Mailing Address - Fax:252-754-2367
Practice Address - Street 1:2060 W 5TH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-9160
Practice Address - Country:US
Practice Address - Phone:252-752-3402
Practice Address - Fax:252-754-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-074-038310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility