Provider Demographics
NPI:1578609228
Name:WAKE ASSISTED LIVING
Entity Type:Organization
Organization Name:WAKE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:BURRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-230-1555
Mailing Address - Street 1:2800 KIDD RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1842
Mailing Address - Country:US
Mailing Address - Phone:919-231-7575
Mailing Address - Fax:919-231-3773
Practice Address - Street 1:2800 KIDD RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1842
Practice Address - Country:US
Practice Address - Phone:919-231-7575
Practice Address - Fax:919-231-3773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL092117310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805522Medicaid