Basic Information
| Provider Information | |||||||||
| NPI: | 1043344609 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODLAND PLACE MANAGEMENT, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WOODLAND PLACE - GREENSBORO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1915 BOULEVARD ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274074513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368551414 | ||||||||
| FaxNumber: | 3368557455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 BOULEVARD ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274074513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368551414 | ||||||||
| FaxNumber: | 3368557455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAHAN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9198292482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-041-053 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7805299 | 05 | NC | MEDICAID |