Provider Demographics
NPI:1013069855
Name:JEANNE CULP MOORE
Entity Type:Organization
Organization Name:JEANNE CULP MOORE
Other - Org Name:FOREVER YOUNG RETREAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:CULP
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-422-6530
Mailing Address - Street 1:44913 BYRD RD
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-7876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:704-422-5221
Practice Address - Street 1:44913 BYRD RD
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-7876
Practice Address - Country:US
Practice Address - Phone:704-422-6530
Practice Address - Fax:704-422-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-084-002310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803511Medicaid