Provider Demographics
NPI:1447398029
Name:DBG III LLC
Entity Type:Organization
Organization Name:DBG III LLC
Other - Org Name:FAIR BLUFF ASSISTED LIVING #1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOLDSTON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:910-754-6621
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-1559
Mailing Address - Country:US
Mailing Address - Phone:910-754-6621
Mailing Address - Fax:
Practice Address - Street 1:225 MINTON ST
Practice Address - Street 2:
Practice Address - City:FAIR BLUFF
Practice Address - State:NC
Practice Address - Zip Code:28439-9590
Practice Address - Country:US
Practice Address - Phone:910-754-6621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-024-005311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805470Medicaid