Provider Demographics
NPI:1992793962
Name:WOODBURY WELLNESS CENTER INC
Entity type:Organization
Organization Name:WOODBURY WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIDGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-270-1443
Mailing Address - Street 1:2778 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-8028
Mailing Address - Country:US
Mailing Address - Phone:910-270-1443
Mailing Address - Fax:910-270-1826
Practice Address - Street 1:2778 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-8028
Practice Address - Country:US
Practice Address - Phone:910-270-1443
Practice Address - Fax:910-270-1826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0300310400000X, 311500000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3415349Medicaid
NC7806631Medicaid
NC3426235Medicaid
NC3426235Medicaid