Basic Information
| Provider Information | |||||||||
| NPI: | 1548392327 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN HOUSE ASSISTED LIVING OF WILKESBORO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9790 | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288150790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364167149 | ||||||||
| FaxNumber: | 3367515430 | ||||||||
| Practice Location | |||||||||
| Address1: | 176 RESTHOME RD | ||||||||
| Address2: | |||||||||
| City: | WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286977145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369733890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 04/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | DODSON | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3364167149 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL 097 009 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7804712 | 05 | NC | MEDICAID |