Healthcare Provider Details

I. General information

NPI: 1962648543
Provider Name (Legal Business Name): LSA ELMS AT TANGLEWOOD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 HARPER RD
CLEMMONS NC
27012-8682
US

IV. Provider business mailing address

3750 HARPER RD
CLEMMONS NC
27012-8682
US

V. Phone/Fax

Practice location:
  • Phone: 336-766-2131
  • Fax: 336-766-2160
Mailing address:
  • Phone: 336-766-2131
  • Fax: 336-766-2160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL034085
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberHAL034085
License Number StateNC

VIII. Authorized Official

Name: MRS. DEBORAH ANN MATHIS
Title or Position: COO
Credential:
Phone: 704-637-2870