MEDICARE: WILORA LAKE HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	NH572	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215979059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILORA LAKE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	6001 WILORA LAKE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-2833
Country	:	US
Telephone Number	:	704-563-2922
Fax Number	:	704-563-2814

Provider Business Practice Location Address
First Line	:	6001 WILORA LAKE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-2833
Country	:	US
Telephone Number	:	704-563-2922
Fax Number	:	704-563-2814

Authorized Official
Title or Position	:	MANAGER
Name	:	TIM LEHNER
Credential	:
Telephone Number	:	770-698-9040

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	09/13/2024

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