Provider Demographics
NPI:1578814588
Name:NC DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
Entity Type:Organization
Organization Name:NC DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LYNETHIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-806-6875
Mailing Address - Street 1:4001 MAIL SERVICE CTR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27699-4001
Mailing Address - Country:US
Mailing Address - Phone:984-204-2982
Mailing Address - Fax:984-204-8344
Practice Address - Street 1:62 LAKE EDEN RD
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-8706
Practice Address - Country:US
Practice Address - Phone:828-257-6800
Practice Address - Fax:919-807-4266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0631314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNH0631OtherSTATE OF NORTH CAROLINA LICENSURE -