Country Club II

Primary specialty

Lodging ProviderTaxonomy code 177F00000X

License

FCL076031 Issued in NC

Legal business name

COUNTRY CLUB II

Practice address

4011 Old Courthouse Rd
Sophia, NC 27350-8866

Phone

(336) 674-6293

NPI assigned

Feb 6, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Ms. Pearlie M. Bullock

Title

Administrator

Phone

(336) 674-6293

Specialties & licenses 1

Addresses

Other identifiers 2

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

{
    "created_epoch": "1170720000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1316087992",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1324 COLTRANE MILL RD",
            "city": "RANDLEMAN",
            "state": "NC",
            "postal_code": "273178020",
            "telephone_number": "336-674-6293"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4011 OLD COURTHOUSE RD",
            "city": "SOPHIA",
            "state": "NC",
            "postal_code": "273508866",
            "telephone_number": "336-674-6293"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY CLUB II",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-06",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BULLOCK",
        "authorized_official_first_name": "PEARLIE",
        "authorized_official_middle_name": "M.",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "336-674-6293",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "177F00000X",
            "taxonomy_group": "",
            "desc": "Lodging",
            "state": "NC",
            "license": "FCL076031",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "MLH076085",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FCL076031",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Lodging Provider in Sophia, NC
• Providers in Sophia, NC by specialty
• Lodging Provider 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.