Provider Demographics
NPI:1336291699
Name:D-POM LLC
Entity Type:Organization
Organization Name:D-POM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:EVERETTE
Authorized Official - Last Name:OATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-641-5452
Mailing Address - Street 1:PO BOX 1634
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-1634
Mailing Address - Country:US
Mailing Address - Phone:252-823-4367
Mailing Address - Fax:252-823-6085
Practice Address - Street 1:2109 SAINT ANDREW ST STE 15A&16
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-2149
Practice Address - Country:US
Practice Address - Phone:252-641-5452
Practice Address - Fax:252-641-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408421Medicaid