NCC203140_Contact Update Record (Leg Resp and Site Contact)_20220714

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 7/14/2022 7:41:29 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Prior Rescission Date This field will populate only if COC has already been rescinded.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? • No
Yes
Billing Email [e-mail]
Billing Telephone No. [phone]
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible
Rick Richards
Individual (Previous)
First Name (New) *
Ruth
Last Name (New)*
Finch
NEW Legally
Reflects any revisions above
Responsible
Ruth Finch
Individual*

Permittee Email
[e-mail]
(Previous)
NEW Permittee
[e-mail]
Email*
Permittee Telephone
918-931-8630
No. (Previous)
NEW Permittee
[phone]
Telephone No.*
Permittee Mailing
2222 South 17th Street, 0, Wilmington, NC
Address (Previous)
28401
NEW Permittee
Street Address
Mailing Address*
1380 North College Road
Address Line 2
City
Wilmington
Postal / Zip Code
28405
Permittee Street
2222 South 17th Street, 0, Wilmington, NC
Address (Previous)
28401
NEW Permittee Street
Street Address
Address*
1380 North College Road
Address Line 2
State / Province / Region
NC
Country
us
City
State / Province / Region
Wilmington
NC
Postal / Zip Code
Country
28405
us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact
Rick Richards
(Previous)
Site Contact Title
CEO
(Previous)
Organization
Elderhaus, Inc.
(Previous)
First Name (New)*
Ruth
Last Name (New) *
Finch
NEW Site Contact*
Reflects any revisions above
Ruth Finch
NEW Site Contact
Executive Director
Title
NEW Organization
Elderhaus, Inc.
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 918-931-8630
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 2222 South 17th Street, 0, Wilmington, NC
Address (Previous) 28401
NEW Site Contact
Street Address
Mailing Address*
1380 North College Road
Address Line 2
City
State / Province / Region
Wilmington
NC
Postal / Zip Code
Country
28405
us
Change Requested
Ruth Finch via e-mail on 7/13/2022
by: *
Include any additional correspondence records in
the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation Rick Richards retired from Elderhaus, Inc.
(Optional)
Date * 07/14/2022