Provider Demographics
NPI:1407843097
Name:STANLEY TOTAL LIVING CENTER, INC
Entity Type:Organization
Organization Name:STANLEY TOTAL LIVING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFELICE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-263-1986
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28164-0489
Mailing Address - Country:US
Mailing Address - Phone:704-263-1986
Mailing Address - Fax:704-263-8959
Practice Address - Street 1:514 OLD MOUNT HOLLY RD
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164-2191
Practice Address - Country:US
Practice Address - Phone:704-263-1986
Practice Address - Fax:704-263-8959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0386311500000X, 311ZA0620X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405264Medicaid
NC0086COtherPROVIDER NUMBER
NC=========OtherPROVIDER NUMBER
NC3405264Medicaid