MEDICARE: LUTHERAN HOME - HICKORY WEST

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	NC0162	NC

General Provider Information

NPI Number	:	1124202759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUTHERAN HOME - HICKORY WEST

Provider Business Mailing Address
First Line	:	1125 10TH STREET BLVD NW
Second Line	:
City	:	HICKORY
State	:	NC
Zip	:	28601-3373
Country	:	US
Telephone Number	:	828-322-6995
Fax Number	:	828-485-0070

Provider Business Practice Location Address
First Line	:	1125 10TH STREET BLVD NW
Second Line	:
City	:	HICKORY
State	:	NC
Zip	:	28601-3373
Country	:	US
Telephone Number	:	828-322-6995
Fax Number	:	828-485-0070

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. GUS FLASKA
Credential	:
Telephone Number	:	828-322-6995

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	02/04/2008

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