Provider Demographics
NPI:1417071457
Name:ENTERPRISE HEALTHCARE OF STATESVILLE
Entity Type:Organization
Organization Name:ENTERPRISE HEALTHCARE OF STATESVILLE
Other - Org Name:JURNEY'S OF STATESVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-998-5001
Mailing Address - Street 1:PO BOX 1678
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-1678
Mailing Address - Country:US
Mailing Address - Phone:336-998-5001
Mailing Address - Fax:336-998-5470
Practice Address - Street 1:1942 VAN HAVEN DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4365
Practice Address - Country:US
Practice Address - Phone:704-878-0046
Practice Address - Fax:704-878-9757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-049-015311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803811Medicaid