Provider Demographics
NPI:1033244090
Name:WHITE OAK MANOR KINGS MOUNTAIN INC
Entity Type:Organization
Organization Name:WHITE OAK MANOR KINGS MOUNTAIN INC
Other - Org Name:WHITE OAK MANOR KINGS MOUNTAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-327-1162
Mailing Address - Street 1:716 SIPES ST
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-2716
Mailing Address - Country:US
Mailing Address - Phone:704-739-8132
Mailing Address - Fax:704-739-8133
Practice Address - Street 1:716 SIPES ST
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-2716
Practice Address - Country:US
Practice Address - Phone:704-739-8132
Practice Address - Fax:704-739-8133
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE OAK MANOR INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0396314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3416027Medicaid
NC3415151Medicaid
NC3415151Medicaid
NC34-5151Medicare ID - Type UnspecifiedMEDICARE