Provider Demographics
NPI:1396232195
Name:SOUTHERN LIVING FOR SENIORS OF BURNSVILLE NC LLC
Entity Type:Organization
Organization Name:SOUTHERN LIVING FOR SENIORS OF BURNSVILLE NC LLC
Other - Org Name:SOUTHERN LIVING FOR SENIORS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-551-2006
Mailing Address - Street 1:270 LOVE FOX RD
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28714-9109
Mailing Address - Country:US
Mailing Address - Phone:828-682-3417
Mailing Address - Fax:
Practice Address - Street 1:270 LOVE FOX RD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28714-9109
Practice Address - Country:US
Practice Address - Phone:828-682-3417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances