Provider Demographics
NPI:1275371015
Name:SUPPORTIVE SPACES ADULT CARE LLC
Entity type:Organization
Organization Name:SUPPORTIVE SPACES ADULT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DESHON
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-671-1989
Mailing Address - Street 1:1513 PARKS VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-9580
Mailing Address - Country:US
Mailing Address - Phone:919-671-1989
Mailing Address - Fax:
Practice Address - Street 1:116 MORGAN DR
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-5959
Practice Address - Country:US
Practice Address - Phone:919-671-1989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home