Provider Demographics
NPI:1437270030
Name:CROSS CREEK MANOR ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:CROSS CREEK MANOR ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TRUTENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-488-4821
Mailing Address - Street 1:231 TREETOP DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-0606
Mailing Address - Country:US
Mailing Address - Phone:910-488-4821
Mailing Address - Fax:910-488-5069
Practice Address - Street 1:231 TREETOP DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-0606
Practice Address - Country:US
Practice Address - Phone:910-488-4821
Practice Address - Fax:910-488-5069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL 026-050310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility