Provider Demographics
NPI:1164648861
Name:THE UNITED METHODIST RETIREMENT HOMES, INCORPORATED
Entity Type:Organization
Organization Name:THE UNITED METHODIST RETIREMENT HOMES, INCORPORATED
Other - Org Name:CROASDAILE VILLAGE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT SECRETARY/CORP EXEC DIR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-384-3001
Mailing Address - Street 1:2600 CROASDAILE FARM PKWY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-1331
Mailing Address - Country:US
Mailing Address - Phone:919-384-2571
Mailing Address - Fax:919-384-2649
Practice Address - Street 1:2600 CROASDAILE FARM PKWY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705
Practice Address - Country:US
Practice Address - Phone:919-384-2571
Practice Address - Fax:919-384-2649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34D0973408OtherCLIA NUMBER
NC34D0973408OtherCLIA NUMBER