Basic Information
| Provider Information | |||||||||
| NPI: | 1992942973 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILKESBORO LIVIG CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 495 ZION HILL RD | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287526304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287383053 | ||||||||
| FaxNumber: | 8287380350 | ||||||||
| Practice Location | |||||||||
| Address1: | 176 RESTHOME RD | ||||||||
| Address2: | |||||||||
| City: | WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286977145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369733890 | ||||||||
| FaxNumber: | 3369733042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2009 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8287383053 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | HAL097012 | NC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | HAL097012 | 01 | NC | LICENSE | OTHER |