Basic Information
| Provider Information | |||||||||
| NPI: | 1265526404 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MECKLENBURG HEALTH CARE CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MECKLENBURG HEALTH & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2917 PENN FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240184374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409893618 | ||||||||
| FaxNumber: | 5407749443 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 SANDY PORTER RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282733695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045830430 | ||||||||
| FaxNumber: | 7045830433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 10/23/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | CLAUDE | ||||||||
| AuthorizedOfficialMiddleName: | NOVEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO, MFA INC. GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5407767526 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH0570 | NC | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | NH0570 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3405471 | 05 | NC | MEDICAID | 340610E | 05 | NC | MEDICAID |