Provider Demographics
NPI:1356490098
Name:CHARLOTTE ASSISTED LIVING
Entity Type:Organization
Organization Name:CHARLOTTE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MGR.
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:WELNICKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-545-7005
Mailing Address - Street 1:8700 LAWYERS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-8740
Mailing Address - Country:US
Mailing Address - Phone:704-545-7005
Mailing Address - Fax:704-545-6613
Practice Address - Street 1:8700 LAWYERS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-8740
Practice Address - Country:US
Practice Address - Phone:704-545-7005
Practice Address - Fax:704-545-6613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-060-068310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805023Medicaid