Provider Demographics
NPI:1619532801
Name:WILDEWOOD RETIREMENT LLC
Entity Type:Organization
Organization Name:WILDEWOOD RETIREMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-815-7341
Mailing Address - Street 1:3530 TORINGDON WAY STE 204
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3436
Mailing Address - Country:US
Mailing Address - Phone:704-246-1620
Mailing Address - Fax:704-246-1621
Practice Address - Street 1:731 POLO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4462
Practice Address - Country:US
Practice Address - Phone:803-788-5115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility