Provider Demographics
NPI:1114063559
Name:FIRST ASSEMBLY LIVING CENTER
Entity Type:Organization
Organization Name:FIRST ASSEMBLY LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PCS COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:MCCLURE
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-793-4760
Mailing Address - Street 1:160 WARREN C COLEMAN BLVD N
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-6786
Mailing Address - Country:US
Mailing Address - Phone:704-793-4760
Mailing Address - Fax:704-793-4764
Practice Address - Street 1:160 WARREN C COLEMAN BLVD N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-6786
Practice Address - Country:US
Practice Address - Phone:704-793-4760
Practice Address - Fax:704-793-4764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-013-000310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801009Medicaid