NCC233659_Contact Update Record_20250127

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Tev.Holloman 1/27/2025 1:23:38 PM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC233659
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2023-3659
Original NOI No.* 173140
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Mountain Vista Health Park Inc.
Project Name Mt.Vista Health Park
Address 106 Mt.Vista Health Park Rd., Denton, NC
County Davidson
Latitude 35.6240
Longitude -80.1189
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Prior Rescission Date This field will populate only if COC has already been rescinded.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
0 Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 336-250-3039
NEW Billing 336-859-2181
Telephone No. (optional)
Change Requested Cindy Montgomery,Administrator,via email on 1/24/2025
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 01/27/2025