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HomeMy WebLinkAboutNCC214002_Contact Update Record_20240814 Action History (UTC-05:00)Eastern Time(US&Canada) Submit by Tev.Holloman 8/14/2024 12:02:40 PM (Contact Changes Submitted) Contact • - for • • • ONLY) updatesThis form • . . Certificate of NCC214002 Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters) NC Reference No. NCG01-2021-4002 Original NOI No.* 58505 Project information associated with this permit(cannot change): Permittee Listed Organizaiton cannot be changed(new COC required) Arbor Acres United Methodist Retirement Community, Inc. Project Name Arbor Acres-Aldersgate Square Address 1240 Arbor Acres,Winston-Salem, NC County Forsyth Latitude 36.1180 Longitude -80.2664 Date COC Issued* 04/01/2024 Prior Rescission Date This field will populate only if COC has already been rescinded.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? Q No C) Yes Billing Email aapplegate@arboracres.org Billing Telephone No. (336)724-7921 Site Contact Information REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES! Site Contact Les Cranfill (Previous) Site Contact Title Project Manager (Previous) Organization Arbor Acres United Methodist Retirement Community, Inc. (Previous) First Name(New)* David Last Name(New)* Matthews NEW Site Contact* Reflects any revisions above David Matthews NEW Site Contact Vice President Title NEW Organization Arbor Acres United Methodist Retirement Community, Inc. This field is not required on the NOI form and may not pre-populate. Site Contact Email Icranfill@arboracres.org (Previous) NEW Site Contact dmatthews@arboracres.org Email* Site Contact (336)462-0308 Telephone No. (Previous) NEW Site Contact (336)721-5911 Telephone No.* Site Contact Mailing 1240 Arbor Road,0,Winston-Salem, NC Address(Previous) 27104 NEW Site Contact Street Address Mailing Address* 1240 Arbor Road Address Line 2 City State/Province/Region Winston-Salem NC Postal/Zip Code Country 27104 US Change Requested David Matthews,Vice President,via email on 8/14/24 by:* Include any additional correspondence records in the Repository COC folder. Additional Information for this update to contact information: Addional Explanation (Optional) Date* 08/14/2024