Basic Information
| Provider Information | |||||||||
| NPI: | 1720039159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GGNSC CHARLOTTE AMERICAN LLC | ||||||||
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| OtherOrganizationName: | GOLDEN LIVINGCENTER - CHARLOTTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 FIANNA WAY | ||||||||
| Address2: | MAIL DROP 4840 | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729194840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778238375 | ||||||||
| FaxNumber: | 4794781878 | ||||||||
| Practice Location | |||||||||
| Address1: | 2616 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282044343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043335165 | ||||||||
| FaxNumber: | 7043726906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/14/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0279 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3425201 | 05 | NC | MEDICAID | 3426210 | 05 | NC | MEDICAID |