Provider Demographics
NPI:1124396171
Name:LAKE JAMES LODGE ASSISTED LIVING, INC.
Entity Type:Organization
Organization Name:LAKE JAMES LODGE ASSISTED LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/CEO/ ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:CRUMMIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-676-9063
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:NC
Mailing Address - Zip Code:28758-0999
Mailing Address - Country:US
Mailing Address - Phone:828-652-3038
Mailing Address - Fax:
Practice Address - Street 1:63 LAKEVIEW DR N
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-8896
Practice Address - Country:US
Practice Address - Phone:828-652-3038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL 059032310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility