Provider Demographics
NPI:1962803551
Name:CARILLON ASSISTED LIVING OF CLEMMONS, LLC
Entity type:Organization
Organization Name:CARILLON ASSISTED LIVING OF CLEMMONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MORIARTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-852-4000
Mailing Address - Street 1:1165 S PEACE HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8910
Mailing Address - Country:US
Mailing Address - Phone:336-766-6220
Mailing Address - Fax:336-766-6221
Practice Address - Street 1:1165 S PEACE HAVEN RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8910
Practice Address - Country:US
Practice Address - Phone:336-766-6220
Practice Address - Fax:336-766-6221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARILLON ASSISTED LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-034-099311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility