Provider Demographics
NPI:1811030497
Name:CEDAR GROVE ASSISTED LIVING
Entity Type:Organization
Organization Name:CEDAR GROVE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAVERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-580-6280
Mailing Address - Street 1:101 DAVELIN PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-4507
Mailing Address - Country:US
Mailing Address - Phone:919-580-9733
Mailing Address - Fax:919-580-9733
Practice Address - Street 1:500 FREE GOSPEL RD
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:NC
Practice Address - Zip Code:28580-8710
Practice Address - Country:US
Practice Address - Phone:252-747-3504
Practice Address - Fax:919-580-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL040005310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility