Healthcare Provider Details

I. General information

NPI: 1083703029
Provider Name (Legal Business Name): WILKES TRADITIONAL LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 OLD BRICKYARD ROAD
NORTH WILKESBORO NC
28659-1227
US

IV. Provider business mailing address

PO BOX 1227 206 OLD BRICKYARD ROAD
NORTH WILKESBORO NC
28659-1227
US

V. Phone/Fax

Practice location:
  • Phone: 336-667-2211
  • Fax: 336-667-8199
Mailing address:
  • Phone: 336-667-2211
  • Fax: 336-667-8199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHHL-097-010
License Number StateNC

VIII. Authorized Official

Name: MS. KENDRA TRIVETTE
Title or Position: ADMINISTRATOR
Credential:
Phone: 336-667-2020