Provider Demographics
NPI:1891761979
Name:OCEAN TRAIL CONVALESCENT CENTER, INC.
Entity Type:Organization
Organization Name:OCEAN TRAIL CONVALESCENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-679-8852
Mailing Address - Street 1:PO BOX 10249
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-0249
Mailing Address - Country:US
Mailing Address - Phone:910-457-9581
Mailing Address - Fax:910-457-9583
Practice Address - Street 1:630 N FODALE AVE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3538
Practice Address - Country:US
Practice Address - Phone:910-457-9581
Practice Address - Fax:910-457-9583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0322314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405373Medicaid
NC0092MOtherBCBS PROVIDER NO
NC3406253Medicaid
NC3406253Medicaid