MEDICARE: COMMONWOOD HOME

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	3104A0625X	Assisted Living Facility (Mental Illness)	MHL-081-026	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	:	1831372804
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWOOD HOME

Provider Business Mailing Address
First Line	:	348 LEONARD LANE
Second Line	:
City	:	ELLENBORO
State	:	NC
Zip	:	28040
Country	:	US
Telephone Number	:	828-453-0367
Fax Number	:	828-453-0367

Provider Business Practice Location Address
First Line	:	348 LEONARD LANE
Second Line	:
City	:	ELLENBORO
State	:	NC
Zip	:	28040
Country	:	US
Telephone Number	:	828-453-0367
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. VIRGINIA P. WALKER
Credential	:
Telephone Number	:	828-453-0367

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	07/12/2011

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Directions to “COMMONWOOD HOME ” Practice Location

Language	Start Address	Practice Location

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