Provider Demographics
NPI:1497260608
Name:PROVIDENCE HEALTHCARE OF THE CAROLINAS
Entity Type:Organization
Organization Name:PROVIDENCE HEALTHCARE OF THE CAROLINAS
Other - Org Name:PROVIDENCE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERMAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-247-4760
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-0464
Mailing Address - Country:US
Mailing Address - Phone:919-247-4760
Mailing Address - Fax:
Practice Address - Street 1:4302 HWY NC 210
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility