MEDICARE: MECKLENBURG HEALTH CARE CENTER, INC.

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	313M00000X	Nursing Facility/Intermediate Care Facility	NH0570	NC
2	314000000X	Skilled Nursing Facility	NH0570	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265526404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECKLENBURG HEALTH CARE CENTER, INC.

Provider Business Mailing Address
First Line	:	2917 PENN FOREST BLVD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-4374
Country	:	US
Telephone Number	:	540-989-3618
Fax Number	:	540-774-9443

Provider Business Practice Location Address
First Line	:	2415 SANDY PORTER RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-3695
Country	:	US
Telephone Number	:	704-583-0430
Fax Number	:	704-583-0433

Authorized Official
Title or Position	:	CFO, MFA INC. GENERAL PARTNER
Name	:	MR. CLAUDE NOVEL MARTIN III
Credential	:
Telephone Number	:	540-776-7526

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	10/23/2013

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