CCJ Adult Care IV LLC

Primary specialty

Custodial Care FacilityTaxonomy code 311Z00000X

Legal business name

CCJ ADULT CARE IV LLC

Practice address

101 Olde Coach Lane
Cherryville, NC 28021

Phone

(980) 295-3020

NPI assigned

Aug 23, 2021

Organization subpart

No

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

Authorized official

Name

Bernice R Hosch

Title

Administrator/Operator

Phone

(980) 295-3020

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Walden Pond Care Home Doing business as

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

{
    "created_epoch": "1629676800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1629763200000",
    "number": "1558038174",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 74",
            "city": "BESSEMER CITY",
            "state": "NC",
            "postal_code": "280160074",
            "telephone_number": "980-295-3020"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 OLDE COACH LANE",
            "city": "CHERRYVILLE",
            "state": "NC",
            "postal_code": "28021",
            "telephone_number": "980-295-3020"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "100 W Main Ave Apt 302",
            "address_purpose": "LOCATION",
            "city": "Gastonia",
            "state": "NC",
            "postal_code": "280524172",
            "country_code": "US",
            "telephone_number": "980-295-3020",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "CCJ ADULT CARE IV LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-08-23",
        "last_updated": "2021-08-24",
        "certification_date": "2021-08-24",
        "status": "A",
        "authorized_official_last_name": "HOSCH",
        "authorized_official_first_name": "BERNICE",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "ADMINISTRATOR/OPERATOR",
        "authorized_official_telephone_number": "980-295-3020"
    },
    "taxonomies": [
        {
            "code": "311Z00000X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE OF NORTH CAROLINA",
            "identifier": "FCL-036-035",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Walden Pond Care Home",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Walden Pond Care Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Priya Chandrasekaran
• Cherryville Dental Clinic
• Cherryville Primary Care
• Cherryville Primary Care

• All providers in Cherryville, NC
• Custodial Care Facility in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 2021; 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.