Provider Demographics
NPI:1124191804
Name:STATESVILLE ASSISTED LIVING
Entity Type:Organization
Organization Name:STATESVILLE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUITVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:BACCALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-778-6719
Mailing Address - Street 1:2147 DAVIE AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-9200
Mailing Address - Country:US
Mailing Address - Phone:704-878-0123
Mailing Address - Fax:704-878-8689
Practice Address - Street 1:2147 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-9200
Practice Address - Country:US
Practice Address - Phone:704-878-0123
Practice Address - Fax:704-878-8689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-049-023305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804765Medicaid