NCC203140_Contact Update Record (Billing)_20220708

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 7/8/2022 10:33:38 AM (Contact Changes Submitted)

Certificate of NCC203140
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2020-3140
Original NOI No.* 28534
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Elderhaus, Inc.
Project Name Elderhaus
Address 1380 N. College Road, Wilmington, NC
County New Hanover
Latitude 34.2670
Longitude-77.8680
Date COC Issued * 07/24/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.
Which Contacts Have • Billing Only
Changed?* Legally Responsible Individual Only
Site Contact Only
BOTH Legally Responsible Individual and Site Contact
Has Billing Contact Choose'Yes'to revise Billing Contact details.
Changed? U No
Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone No.
NEW Billing [phone]
Telephone No. (Optional)
Change Requested Ruth Finch via e-mail on 7/1/2022. (She indicated that Rick Richards (legally
by: * responsible individual and site contact) retired, but we have not yet received a
signed form to update that info.)
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)

Date * 07/08/2022