Statesville Assisted Living

Primary specialty

Preferred Provider OrganizationTaxonomy code 305R00000X

License

HAL-049-023 Issued in NC

Legal business name

STATESVILLE ASSISTED LIVING

Practice address

2147 Davie Ave
Statesville, NC 28625-9200

Phone

(704) 878-0123

Fax

(704) 878-8689

NPI assigned

Nov 17, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Aldo Baccala

Title

Execuitve Officer

Phone

(707) 778-6719

Specialties & licenses 1

Addresses

Other identifiers 1

Tax ID family

Statesville Assisted Living2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Statesville Assisted Living, LLC

  • Assisted Living Facility
  • Statesville, NC
  • NPI 1659580819
  NPD tax ID

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163721600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1124191804",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2147 DAVIE AVE",
            "city": "STATESVILLE",
            "state": "NC",
            "postal_code": "286259200",
            "telephone_number": "704-878-0123",
            "fax_number": "704-878-8689"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2147 DAVIE AVE",
            "city": "STATESVILLE",
            "state": "NC",
            "postal_code": "286259200",
            "telephone_number": "704-878-0123",
            "fax_number": "704-878-8689"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATESVILLE ASSISTED LIVING",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-17",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BACCALA",
        "authorized_official_first_name": "ALDO",
        "authorized_official_title_or_position": "EXECUITVE OFFICER",
        "authorized_official_telephone_number": "707-778-6719",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "NC",
            "license": "HAL-049-023",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7804765",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Benjamin Robert Stacy, D.O.
• Amy Stamper
• Adam Stapleton, PA-C
• Jessica Starr, ATC
• Statesville Amy Kinlaw PLLC
• Statesville Assisted Living, LLC
• Statesville Cardiovascular Clinic PA
• Statesville Childrens Clinic PA
• Statesville Dialysis Center of Wake Forest University
• Statesville Hma Inc

• Preferred Provider Organization in Statesville, NC
• Providers in Statesville, NC by specialty
• Preferred Provider Organization in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.