Basic Information
Provider Information | |||||||||
NPI: | 1952545592 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELKIN RETIREMENT COMMUNITY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 814 | ||||||||
Address2: |   | ||||||||
City: | RANDLEMAN | ||||||||
State: | NC | ||||||||
PostalCode: | 273170814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3364952700 | ||||||||
FaxNumber: | 3364955552 | ||||||||
Practice Location | |||||||||
Address1: | 500 JOHNSON RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | ELKIN | ||||||||
State: | NC | ||||||||
PostalCode: | 286212420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368356672 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2009 | ||||||||
LastUpdateDate: | 06/13/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILSON | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | DEAN | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 3364952700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X |   |   | N |   | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home | 310400000X | HAL-086-013 | NC | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 7806495 | 05 | NC |   | MEDICAID |