Provider Demographics
NPI:1285770933
Name:WILSON ASSISTED LIVING
Entity type:Organization
Organization Name:WILSON ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:BURRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-230-1555
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27894-0188
Mailing Address - Country:US
Mailing Address - Phone:252-243-3186
Mailing Address - Fax:252-243-3187
Practice Address - Street 1:3501 SENIOR VILLAGE LN NW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-9618
Practice Address - Country:US
Practice Address - Phone:252-243-3186
Practice Address - Fax:252-243-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL098024310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805531Medicaid