Provider Demographics
NPI:1710031828
Name:SANDY RIDGE HOMES HOLDING CORP.
Entity Type:Organization
Organization Name:SANDY RIDGE HOMES HOLDING CORP.
Other - Org Name:SANDY RIDGE ASSISED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:LOWA
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:910-974-4162
Mailing Address - Street 1:326 BOWMAN RD
Mailing Address - Street 2:
Mailing Address - City:CANDOR
Mailing Address - State:NC
Mailing Address - Zip Code:27229-9682
Mailing Address - Country:US
Mailing Address - Phone:910-974-4162
Mailing Address - Fax:910-974-6038
Practice Address - Street 1:326 BOWMAN RD
Practice Address - Street 2:
Practice Address - City:CANDOR
Practice Address - State:NC
Practice Address - Zip Code:27229-9682
Practice Address - Country:US
Practice Address - Phone:910-974-4162
Practice Address - Fax:910-974-6038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-062-009310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804197Medicaid