Provider Demographics
NPI:1740339126
Name:SHELBY MANOR GROUP HOME
Entity type:Organization
Organization Name:SHELBY MANOR GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-628-5000
Mailing Address - Street 1:100 ABINGDON PL
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-6122
Mailing Address - Country:US
Mailing Address - Phone:276-628-5000
Mailing Address - Fax:276-623-2148
Practice Address - Street 1:1176 WYKE RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4273
Practice Address - Country:US
Practice Address - Phone:276-628-5000
Practice Address - Fax:276-623-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL023008311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803639Medicaid