Provider Demographics
NPI:1043241748
Name:WOODLAWN RETIREMENT HOME
Entity Type:Organization
Organization Name:WOODLAWN RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:252-492-0066
Mailing Address - Street 1:2275 RUIN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27537-8732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2171 RUIN CREEK RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27537-8735
Practice Address - Country:US
Practice Address - Phone:252-492-0066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SENIOR CITIZENS HOME INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-091-003310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801463Medicaid