# OCEAN TRAIL CONVALESCENT CENTER

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699961540
- **Authorized official:** MR. NICK W ELLEDGE (VICE PRESIDENT)
- **Authorized official phone:** (336) 679-8852

## Contact information

- **Practice address:** 630 N FODALE AVE, SOUTHPORT, NC 28461-3538
- **Practice address phone:** (910) 457-9581
- **Practice address fax:** (910) 457-9583
- **Mailing address:** PO BOX 10249, SOUTHPORT, NC 28461-0249
- **Mailing address phone:** (910) 457-9581
- **Mailing address fax:** (910) 457-9583

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 311ZA0620X | Adult Care Home Facility | NH0322 | NC | Yes |

## Other

- **Enumeration date:** 09/24/2007
- **Last updated:** 06/23/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 7801188 | — | NC |