Provider Demographics
NPI:1588192280
Name:BROOKSTONE OF CLEMMONS, LLC
Entity Type:Organization
Organization Name:BROOKSTONE OF CLEMMONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-687-2580
Mailing Address - Street 1:PO BOX 1682
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-1682
Mailing Address - Country:US
Mailing Address - Phone:336-766-5000
Mailing Address - Fax:336-766-5020
Practice Address - Street 1:4430 CLINARD RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8487
Practice Address - Country:US
Practice Address - Phone:336-766-5000
Practice Address - Fax:336-766-5020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-034-102310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility