Basic Information
| Provider Information | |||||||||
| NPI: | 1770538092 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAUREL HEALTH CARE COMPANY OF NORTH CAROLINA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE LAURELS OF HENDERSONVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8181 WORTHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430828067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147948800 | ||||||||
| FaxNumber: | 6147948826 | ||||||||
| Practice Location | |||||||||
| Address1: | 2220 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287922438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286926000 | ||||||||
| FaxNumber: | 8286926804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 06/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | ANIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6147948800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH0480 | NC | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | NH0480 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3415322 | 05 | NC | MEDICAID | 0097X | 01 | NC | BLUE CROSS BLUE SHIELD # | OTHER | NH0480 | 01 | NC | NURSING HOME LICENSE # | OTHER | 3416589 | 05 | NC | MEDICAID |