Provider Demographics
NPI:1841697422
Name:CORNELIA NIXON DAVIS, INC.
Entity type:Organization
Organization Name:CORNELIA NIXON DAVIS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR (CEO)
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-686-7195
Mailing Address - Street 1:1011 PORTERS NECK RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9196
Mailing Address - Country:US
Mailing Address - Phone:910-319-2111
Mailing Address - Fax:910-686-7592
Practice Address - Street 1:83 CAVALIER DR.
Practice Address - Street 2:200
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-4444
Practice Address - Country:US
Practice Address - Phone:910-319-2111
Practice Address - Fax:910-686-7592
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORNELIA NIXON DAVIS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-26
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0645314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405568Medicaid