Provider Demographics
NPI:1588796791
Name:CHERRY, VANDERBILL JR
Entity Type:Individual
Prefix:MR
First Name:VANDERBILL
Middle Name:
Last Name:CHERRY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 CHARLES TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:AULANDER
Mailing Address - State:NC
Mailing Address - Zip Code:27805-9770
Mailing Address - Country:US
Mailing Address - Phone:252-345-3732
Mailing Address - Fax:252-345-8318
Practice Address - Street 1:1215 CHARLES TAYLOR RD
Practice Address - Street 2:
Practice Address - City:AULANDER
Practice Address - State:NC
Practice Address - Zip Code:27805-9770
Practice Address - Country:US
Practice Address - Phone:252-345-3732
Practice Address - Fax:252-345-8318
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-008-001311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801392Medicaid
NC7803061Medicaid