Provider Demographics
NPI:1679624431
Name:LAWYERS GLEN RETIREMENT LIVING CENTER LLC
Entity type:Organization
Organization Name:LAWYERS GLEN RETIREMENT LIVING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELLIOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-545-9555
Mailing Address - Street 1:10830 LAWYERS GLEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227
Mailing Address - Country:US
Mailing Address - Phone:704-545-9555
Mailing Address - Fax:704-545-2075
Practice Address - Street 1:10830 LAWYERS GLEN DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227
Practice Address - Country:US
Practice Address - Phone:704-545-9555
Practice Address - Fax:704-545-2075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804718Medicaid