Provider Demographics
NPI:1104060565
Name:MOUNTAIN TRACE ENTERPRISE LLC
Entity type:Organization
Organization Name:MOUNTAIN TRACE ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:STROHLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-864-9191
Mailing Address - Street 1:417 MOUNTAIN TRACE RD
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-6779
Mailing Address - Country:US
Mailing Address - Phone:828-631-1600
Mailing Address - Fax:828-631-1605
Practice Address - Street 1:417 MOUNTAIN TRACE RD
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-6779
Practice Address - Country:US
Practice Address - Phone:828-631-1600
Practice Address - Fax:828-631-1605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0623314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC341-6484Medicaid
NC341-5302Medicaid
NC345302Medicare Oscar/Certification