Provider Demographics
NPI:1104273093
Name:AC MYRTLE GROVE
Entity type:Organization
Organization Name:AC MYRTLE GROVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPY ASSISTAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:910-792-1455
Mailing Address - Street 1:5725 CAROLINA BEACH RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2611
Mailing Address - Country:US
Mailing Address - Phone:910-792-1455
Mailing Address - Fax:910-792-1492
Practice Address - Street 1:5725 CAROLINA BEACH RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2611
Practice Address - Country:US
Practice Address - Phone:910-792-1455
Practice Address - Fax:910-792-1492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5811314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility