Provider Demographics
NPI:1457674574
Name:AVALON # 3
Entity Type:Organization
Organization Name:AVALON # 3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IJEOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NWANKWO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-253-2219
Mailing Address - Street 1:4428 LOUISBURG RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-4302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4133 WHITE PINE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-3737
Practice Address - Country:US
Practice Address - Phone:336-253-2219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home