Provider Demographics
NPI:1962648543
Name:LSA ELMS AT TANGLEWOOD, INC.
Entity Type:Organization
Organization Name:LSA ELMS AT TANGLEWOOD, INC.
Other - Org Name:ELMS AT TANGLEWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-637-2870
Mailing Address - Street 1:3750 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8682
Mailing Address - Country:US
Mailing Address - Phone:336-766-2131
Mailing Address - Fax:336-766-2160
Practice Address - Street 1:3750 HARPER RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8682
Practice Address - Country:US
Practice Address - Phone:336-766-2131
Practice Address - Fax:336-766-2160
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN SERVICES FOR THE AGING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL034085310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)