Provider Demographics
NPI:1326126475
Name:LUCORJA FAMILY CARE HOME
Entity Type:Organization
Organization Name:LUCORJA FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORLISS
Authorized Official - Middle Name:L
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-563-1020
Mailing Address - Street 1:4701 FREEDOM DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-1719
Mailing Address - Country:US
Mailing Address - Phone:704-398-9574
Mailing Address - Fax:704-392-5524
Practice Address - Street 1:5356 COBURG AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-2202
Practice Address - Country:US
Practice Address - Phone:704-563-1020
Practice Address - Fax:704-563-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCI060069310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805039Medicaid