1326126475 NPI number — LUCORJA FAMILY CARE HOME

Table of content: (NPI 1326126475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326126475 NPI number — LUCORJA FAMILY CARE HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUCORJA FAMILY CARE HOME
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:
Provider Other Organization Name Type Code:
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:
1326126475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4701 FREEDOM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28208-1719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-398-9574
Provider Business Mailing Address Fax Number:
704-392-5524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5356 COBURG AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28215-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-563-1020
Provider Business Practice Location Address Fax Number:
704-563-1072
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOKE
Authorized Official First Name:
CORLISS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
704-563-1020

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  FCI060069 , 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: 7805039 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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