Organization
COUNTRY CLUB II
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. PEARLIE M. BULLOCK (ADMINISTRATOR)
(336) 674-6293
Entity
Organization
Contact information
Practice address
4011 OLD COURTHOUSE RD, SOPHIA, NC 27350-8866
(336) 674-6293
Mailing address
1324 COLTRANE MILL RD, RANDLEMAN, NC 27317-8020
(336) 674-6293
Taxonomy
Speciality
Code
Description
License number
State
177F00000X
Lodging Provider
Primary
FCL076031
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
FCL076031
—
NC
05
—
MLH076085
—
NC
Enumeration date
02/06/2007
Last updated
08/22/2020
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