Provider Demographics
NPI:1548529738
Name:PRESTIGE ESTATES ASSISTED LIVING, INC
Entity type:Organization
Organization Name:PRESTIGE ESTATES ASSISTED LIVING, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMIN
Authorized Official - Prefix:MISS
Authorized Official - First Name:DONNESSA
Authorized Official - Middle Name:LAMEKA
Authorized Official - Last Name:DARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-519-1602
Mailing Address - Street 1:PO BOX 15940
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704
Mailing Address - Country:US
Mailing Address - Phone:919-797-0062
Mailing Address - Fax:919-797-0514
Practice Address - Street 1:4120 HOLT SCHOOL RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1439
Practice Address - Country:US
Practice Address - Phone:919-797-0062
Practice Address - Fax:919-797-0514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7806692Medicaid