Provider Demographics
NPI:1609886159
Name:WILLOW RIDGE OF NC, LLC
Entity Type:Organization
Organization Name:WILLOW RIDGE OF NC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-377-2400
Mailing Address - Street 1:237 TRYON RD
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-3058
Mailing Address - Country:US
Mailing Address - Phone:828-286-7200
Mailing Address - Fax:828-287-3668
Practice Address - Street 1:237 TRYON RD
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-3058
Practice Address - Country:US
Practice Address - Phone:828-286-7200
Practice Address - Fax:828-287-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0590314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3435197Medicaid
NC345197Medicare Oscar/Certification