Provider Demographics
NPI:1619972213
Name:MOUNTAINLIFE HOME CARE, INC.
Entity Type:Organization
Organization Name:MOUNTAINLIFE HOME CARE, INC.
Other - Org Name:MOUNTAINLIFE IN-HOME AIDE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAMMITT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:336-846-1784
Mailing Address - Street 1:PO BOX 1784
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28694-1784
Mailing Address - Country:US
Mailing Address - Phone:336-846-1784
Mailing Address - Fax:336-846-1785
Practice Address - Street 1:411 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9519
Practice Address - Country:US
Practice Address - Phone:336-846-1784
Practice Address - Fax:336-846-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2576251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0719745OtherNC CORPORATE ID NUMBER
NC040720OtherNC DHHS DFS FACILITY ID
NC6601120Medicaid
NC3408136Medicaid