Basic Information
| Provider Information | |||||||||
| NPI: | 1699886085 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGHLAND HOUSE OF FAYETTEVILLE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HIGHLAND HOUSE REHABILITATION & HEALTHCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 PAMALEE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283012824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882295 | ||||||||
| FaxNumber: | 9104880087 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 PAMALEE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283012824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882295 | ||||||||
| FaxNumber: | 9104880087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELLER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 3369985001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0117 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3405353 | 05 | NC | MEDICAID | 3406055 | 05 | NC | MEDICAID | 7801640 | 05 | NC | MEDICAID |