Provider Demographics
NPI:1154574820
Name:SMIL MOUNTAIN LAKE RETIREMENT VILLAGE
Entity type:Organization
Organization Name:SMIL MOUNTAIN LAKE RETIREMENT VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-237-2268
Mailing Address - Street 1:115 RETIREMENT DR
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:VA
Mailing Address - Zip Code:24101
Mailing Address - Country:US
Mailing Address - Phone:540-719-2900
Mailing Address - Fax:
Practice Address - Street 1:115 RETIREMENT DR
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101
Practice Address - Country:US
Practice Address - Phone:540-719-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARO-08-300310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility