Provider Demographics
NPI:1215979059
Name:WILORA LAKE HEALTHCARE LLC
Entity type:Organization
Organization Name:WILORA LAKE HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-698-9040
Mailing Address - Street 1:6001 WILORA LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-2833
Mailing Address - Country:US
Mailing Address - Phone:704-563-2922
Mailing Address - Fax:704-563-2814
Practice Address - Street 1:6001 WILORA LAKE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-2833
Practice Address - Country:US
Practice Address - Phone:704-563-2922
Practice Address - Fax:704-563-2814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH572314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1215979059Medicaid
NC342610XMedicaid
NC7805116Medicaid
NC7805116Medicaid