Provider Demographics
NPI:1558038174
Name:CCJ ADULT CARE IV LLC
Entity type:Organization
Organization Name:CCJ ADULT CARE IV LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-295-3020
Mailing Address - Street 1:PO BOX 74
Mailing Address - Street 2:
Mailing Address - City:BESSEMER CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28016-0074
Mailing Address - Country:US
Mailing Address - Phone:980-295-3020
Mailing Address - Fax:
Practice Address - Street 1:101 OLDE COACH LANE
Practice Address - Street 2:
Practice Address - City:CHERRYVILLE
Practice Address - State:NC
Practice Address - Zip Code:28021
Practice Address - Country:US
Practice Address - Phone:980-295-3020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-23
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FCL-036-035OtherSTATE OF NORTH CAROLINA