Provider Demographics
NPI:1760639199
Name:417 MOUNTAIN TRACE LLC
Entity Type:Organization
Organization Name:417 MOUNTAIN TRACE LLC
Other - Org Name:MOUNTAIN TRACE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:N/A
Authorized Official - Last Name:SHAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:305-864-9191
Mailing Address - Street 1:417 MOUNTAIN TRACE RD
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-6779
Mailing Address - Country:US
Mailing Address - Phone:828-631-1600
Mailing Address - Fax:
Practice Address - Street 1:417 MOUNTAIN TRACE RD
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-6779
Practice Address - Country:US
Practice Address - Phone:828-631-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility