Provider Demographics
NPI:1578583381
Name:PIEDMONT VILLAGE AT STATESVILLE, INC.
Entity Type:Organization
Organization Name:PIEDMONT VILLAGE AT STATESVILLE, INC.
Other - Org Name:PIEDMONT VILLAGE AT STATESVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-627-0664
Mailing Address - Street 1:2979 PGA BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2911
Mailing Address - Country:US
Mailing Address - Phone:561-627-0664
Mailing Address - Fax:561-627-2867
Practice Address - Street 1:1902 ORA DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-6343
Practice Address - Country:US
Practice Address - Phone:704-878-6376
Practice Address - Fax:704-878-6787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-049-014310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803560Medicaid