Provider Demographics
NPI:1790972370
Name:LUTHERAN HOME AT TRINITY OAKS
Entity Type:Organization
Organization Name:LUTHERAN HOME AT TRINITY OAKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-637-3784
Mailing Address - Street 1:820 KLUMAC RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-5722
Mailing Address - Country:US
Mailing Address - Phone:704-637-3784
Mailing Address - Fax:704-636-9464
Practice Address - Street 1:820 KLUMAC RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-5722
Practice Address - Country:US
Practice Address - Phone:704-637-3784
Practice Address - Fax:704-636-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0197385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408422Medicaid