Provider Demographics
NPI:1053691907
Name:MOUNTAIN LIVING ADULT CARE HOME
Entity type:Organization
Organization Name:MOUNTAIN LIVING ADULT CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-846-2424
Mailing Address - Street 1:121 BROOK ST
Mailing Address - Street 2:P.O. BOX 240
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-9643
Mailing Address - Country:US
Mailing Address - Phone:336-846-2424
Mailing Address - Fax:336-846-2424
Practice Address - Street 1:121 BROOK ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9643
Practice Address - Country:US
Practice Address - Phone:336-846-2424
Practice Address - Fax:336-846-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-005-014261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service