1104060565 NPI number — MOUNTAIN TRACE ENTERPRISE LLC

Table of content: (NPI 1104060565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104060565 NPI number — MOUNTAIN TRACE ENTERPRISE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN TRACE ENTERPRISE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOUNTAIN TRACE NURSING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104060565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417 MOUNTAIN TRACE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYLVA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28779-6779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-631-1600
Provider Business Mailing Address Fax Number:
828-631-1605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
417 MOUNTAIN TRACE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLVA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28779-6779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-631-1600
Provider Business Practice Location Address Fax Number:
828-631-1605
Provider Enumeration Date:
04/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
STROHLI
Authorized Official First Name:
ELI
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
305-864-9191

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH0623 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 341-6484 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 341-5302 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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