Provider Demographics
NPI:1659636173
Name:SER
Entity Type:Organization
Organization Name:SER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARICKEYO
Authorized Official - Middle Name:SENTWAN
Authorized Official - Last Name:HUSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-600-6710
Mailing Address - Street 1:208 LESLIE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152-0758
Mailing Address - Country:US
Mailing Address - Phone:704-600-6480
Mailing Address - Fax:704-600-6480
Practice Address - Street 1:208 LESLIE DR
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-0758
Practice Address - Country:US
Practice Address - Phone:704-600-6480
Practice Address - Fax:704-600-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home