Provider Demographics
NPI:1801916796
Name:ST.MARYS ASSITED LIVING FACILITY
Entity type:Organization
Organization Name:ST.MARYS ASSITED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-843-5461
Mailing Address - Street 1:PO BOX 706
Mailing Address - Street 2:
Mailing Address - City:RED SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28377-0706
Mailing Address - Country:US
Mailing Address - Phone:910-843-5461
Mailing Address - Fax:910-843-2978
Practice Address - Street 1:104 HOPE LANE
Practice Address - Street 2:
Practice Address - City:RED SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28377-9999
Practice Address - Country:US
Practice Address - Phone:910-843-5461
Practice Address - Fax:910-843-2978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL078-052310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805487Medicaid