Provider Demographics
NPI:1942274097
Name:TRADITIONAL LIVING HOME CARE INC.
Entity Type:Organization
Organization Name:TRADITIONAL LIVING HOME CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-667-4546
Mailing Address - Street 1:1550 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-2610
Mailing Address - Country:US
Mailing Address - Phone:336-667-6447
Mailing Address - Fax:336-667-2621
Practice Address - Street 1:101 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-2422
Practice Address - Country:US
Practice Address - Phone:336-667-4546
Practice Address - Fax:336-667-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2784251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601897Medicaid