Provider Demographics
NPI:1689700809
Name:CONCORD HOUSE LLC
Entity Type:Organization
Organization Name:CONCORD HOUSE LLC
Other - Org Name:CONCORD HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-738-3046
Mailing Address - Street 1:2339 ODELL SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-7454
Mailing Address - Country:US
Mailing Address - Phone:704-785-9501
Mailing Address - Fax:704-786-1497
Practice Address - Street 1:2339 ODELL SCHOOL RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-7454
Practice Address - Country:US
Practice Address - Phone:704-785-9501
Practice Address - Fax:704-786-1497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL013031310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805307Medicaid