Provider Demographics
NPI:1114735156
Name:1810 CONCORD LAKE ROAD OPCO LLC
Entity type:Organization
Organization Name:1810 CONCORD LAKE ROAD OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-698-9040
Mailing Address - Street 1:1810 CONCORD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6434
Mailing Address - Country:US
Mailing Address - Phone:704-933-3781
Mailing Address - Fax:704-933-5002
Practice Address - Street 1:1810 CONCORD LAKE RD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6434
Practice Address - Country:US
Practice Address - Phone:704-933-3781
Practice Address - Fax:704-933-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-23
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1669410312Medicaid