Basic Information
| Provider Information | |||||||||
| NPI: | 1033244090 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITE OAK MANOR KINGS MOUNTAIN INC | ||||||||
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| OtherOrganizationName: | WHITE OAK MANOR KINGS MOUNTAIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 716 SIPES ST | ||||||||
| Address2: | |||||||||
| City: | KINGS MOUNTAIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280862716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047398132 | ||||||||
| FaxNumber: | 7047398133 | ||||||||
| Practice Location | |||||||||
| Address1: | 716 SIPES ST | ||||||||
| Address2: | |||||||||
| City: | KINGS MOUNTAIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280862716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047398132 | ||||||||
| FaxNumber: | 7047398133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | HANEY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | JOE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8643271162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITE OAK MANOR INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0396 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3416027 | 05 | NC | MEDICAID | 3415151 | 05 | NC | MEDICAID |