Provider Demographics
NPI:1013088392
Name:PARKWOOD VILLAGE, LLC
Entity Type:Organization
Organization Name:PARKWOOD VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-237-9050
Mailing Address - Street 1:1730 PARKWOOD BLVD W
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-3564
Mailing Address - Country:US
Mailing Address - Phone:252-237-9050
Mailing Address - Fax:252-237-9093
Practice Address - Street 1:1730 PARKWOOD BLVD W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3564
Practice Address - Country:US
Practice Address - Phone:252-237-9050
Practice Address - Fax:252-237-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-098-018310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805118Medicaid