NCC192774_Contact Update Record_20210127

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Selkane, Aziza 1/27/2021 3:30:52 PM (Contact Changes Submitted)

•
Certificate of NCC192774
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2019-2774
Original NOI No.* 18441
Project information associated with this permit (cannot change):
Permittee Listed
Organizaiton cannot be changed (new CDC required)
Tri-County Community Health Council, Inc. DBA Commwell Health
Project Name
Cornwell Health New Parking Lot
Address
6114 US Highway 301, Four Oaks, NC
County
Johnston
Latitude
35.4465
Longitude
-78.4238
Date COC Issued*
11/21/2019
Prior Rescission
This field will populate only if COChas already been rescinded.
Date
Which Contacts
f Billing Only
Have Changed?*
r Legally Responsible Individual Only
f Site Contact Only
r BOTH Legally Responsible Individual and Site Contact
Has Billing Contact
Choose'Yes'torevise Billing Contact details.
Changed?
F No
f Yes
Billing Email
[e-mail]
Billing Telephone
910-567-7131
No.
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Pamela Tripp
Individual
(Previous)
First Name (New)* Pamela
Last Name (New) * Tripp

NEW Legally Peflects any revisions above
Responsible Pamela Tripp
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 910-567-7113
Telephone No.
(Previous)
NEW Permittee 910-567-7113
Telephone No.*
Permittee Mailing P.O. Box227, 0, Newton Grove, NC 28366
Address (Previous)
NEW Permittee
Mailing Address*
Street Address
P.O. Box 340
Address Line 2
City
Four Oaks
Fbstal / Zip Code
27524
Permittee Street 3331 Easy Street, 0, Newton Grove, NC
Address (Previous) 28366
NEW Permittee Street Address
Street Address* 6114 US Hwy 301 S.
Address Line 2
city
Four Oaks
Fbstal / Zip Code
27524
State / Rovince / Fbgion
NC
Country
US
State / Fkovince / Region
NC
Country
US
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact
Pamela Tripp
(Previous)
Site Contact Title
CEO
(Previous)
Organization
Commwell Health
(Previous)
First Name (New)*
Pamela
Last Name (New) *
Tripp
NEW Site Contact*
Reflects any revisions above
Pamela Tripp

NEW Site Contact CEO
Title
NEW Organization Commwell Health
This field is not required on the NOI form and may not pre -populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact 910-567-7113
Telephone No.
(Previous)
NEW Site Contact 910-567-7113
Telephone No.*
Site Contact Mailing 3331 Easy Street, 0, Newton Grove, NC
Address (Previous) 28366
NEW Site Contact Street Address
Mailing Address* P.O. Box340
Address Line 2
City
State / Rovince / Fbgion
Four Oaks
NC
Fbstal / Zip Code
Country
27524
us
Change Requested Rene Johnson
by: * Include any additional correspondence records in the Fbpository 00Cfolder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 01 /27/2021