Provider Demographics
NPI:1386704336
Name:NCAL-CHERRYVILLE, INC.
Entity type:Organization
Organization Name:NCAL-CHERRYVILLE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-724-1000
Mailing Address - Street 1:1105 BROOKSTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2524
Mailing Address - Country:US
Mailing Address - Phone:336-724-1000
Mailing Address - Fax:336-724-9955
Practice Address - Street 1:401 W ACADEMY ST
Practice Address - Street 2:
Practice Address - City:CHERRYVILLE
Practice Address - State:NC
Practice Address - Zip Code:28021-3101
Practice Address - Country:US
Practice Address - Phone:704-445-1554
Practice Address - Fax:704-445-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-036017311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804013Medicaid