Provider Demographics
NPI:1528373826
Name:WHITE OAK MANOR-CHARLOTTE
Entity Type:Organization
Organization Name:WHITE OAK MANOR-CHARLOTTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-327-1162
Mailing Address - Street 1:4009 CRAIG AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2505
Mailing Address - Country:US
Mailing Address - Phone:704-365-2620
Mailing Address - Fax:704-365-2624
Practice Address - Street 1:130 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-5113
Practice Address - Country:US
Practice Address - Phone:864-327-1162
Practice Address - Fax:864-573-9107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE OAK MANOR INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0350314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409244OtherMEDICAID-CAP