Basic Information
Provider Information | |||||||||
NPI: | 1215063441 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILLOW RIDGE ASSISTED LIVING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WILLOW RIDGE ASSISTED LIVING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2140 MILTON RD | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282153319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7045637650 | ||||||||
FaxNumber: | 7045356950 | ||||||||
Practice Location | |||||||||
Address1: | 2140 MILTON RD | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282153319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7045637650 | ||||||||
FaxNumber: | 7045356950 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HODGES | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8287383046 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL060070 | NC | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 7805586 | 05 | NC |   | MEDICAID |