Provider Demographics
NPI:1124162300
Name:CAROLYN BOONE LEWIS HEALTH CARE CENTER INC
Entity type:Organization
Organization Name:CAROLYN BOONE LEWIS HEALTH CARE CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:B
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-686-9010
Mailing Address - Street 1:1380 SOUTHERN AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-4623
Mailing Address - Country:US
Mailing Address - Phone:202-279-5828
Mailing Address - Fax:
Practice Address - Street 1:1380 SOUTHERN AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4623
Practice Address - Country:US
Practice Address - Phone:202-279-5828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCB131064314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC022869900Medicaid
DC022869900Medicaid