Provider Demographics
NPI:1922142256
Name:IRENE WORTHAM RESIDENTIAL CENTER, INC.
Entity Type:Organization
Organization Name:IRENE WORTHAM RESIDENTIAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:R. MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-274-7518
Mailing Address - Street 1:916 WEST CHAPEL ROAD,
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-2844
Mailing Address - Country:US
Mailing Address - Phone:828-274-7518
Mailing Address - Fax:828-274-1582
Practice Address - Street 1:1 ROSE ST W
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2857
Practice Address - Country:US
Practice Address - Phone:828-274-7518
Practice Address - Fax:828-274-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-011-022315P00000X
NC320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406413Medicaid