Provider Demographics
NPI:1083779383
Name:NCAL - ROCKY MOUNT, INC.
Entity Type:Organization
Organization Name:NCAL - ROCKY MOUNT, INC.
Other - Org Name:SOMERSERT COURT OF ROCKY MOUNT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-724-1000
Mailing Address - Street 1:1105 BROOKSTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2524
Mailing Address - Country:US
Mailing Address - Phone:336-724-1000
Mailing Address - Fax:336-724-9955
Practice Address - Street 1:918 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-2532
Practice Address - Country:US
Practice Address - Phone:252-443-5592
Practice Address - Fax:252-446-6969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-064-010311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804017Medicaid