Provider Demographics
NPI:1215024682
Name:CLIMBING JACOBS LADDER LLC
Entity Type:Organization
Organization Name:CLIMBING JACOBS LADDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-760-5516
Mailing Address - Street 1:7475 PRINCESS ANNE CT
Mailing Address - Street 2:SUITE -B
Mailing Address - City:RURAL
Mailing Address - State:NC
Mailing Address - Zip Code:27045-9821
Mailing Address - Country:US
Mailing Address - Phone:336-760-5516
Mailing Address - Fax:336-760-5517
Practice Address - Street 1:3401 HEALY DR
Practice Address - Street 2:SUITE-B
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1450
Practice Address - Country:US
Practice Address - Phone:336-760-5516
Practice Address - Fax:336-760-5517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301092Medicaid