Provider Demographics
NPI:1548392327
Name:MOUNTAIN HOUSE ASSISTED LIVING OF WILKESBORO, LLC
Entity Type:Organization
Organization Name:MOUNTAIN HOUSE ASSISTED LIVING OF WILKESBORO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-416-7149
Mailing Address - Street 1:PO BOX 9790
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28815-0790
Mailing Address - Country:US
Mailing Address - Phone:336-416-7149
Mailing Address - Fax:336-751-5430
Practice Address - Street 1:176 RESTHOME RD
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-7145
Practice Address - Country:US
Practice Address - Phone:336-973-3890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL 097 009310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804712Medicaid