Provider Demographics
NPI:1316087992
Name:COUNTRY CLUB II
Entity type:Organization
Organization Name:COUNTRY CLUB II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PEARLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-674-6293
Mailing Address - Street 1:1324 COLTRANE MILL RD
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317-8020
Mailing Address - Country:US
Mailing Address - Phone:336-674-6293
Mailing Address - Fax:
Practice Address - Street 1:4011 OLD COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:SOPHIA
Practice Address - State:NC
Practice Address - Zip Code:27350-8866
Practice Address - Country:US
Practice Address - Phone:336-674-6293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL076031177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes177F00000XOther Service ProvidersLodgingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFCL076031Medicaid
NCMLH076085Medicaid