Provider Demographics
NPI:1386763266
Name:C.R.T. GOLDEN LAMB REST HOME, INC.
Entity type:Organization
Organization Name:C.R.T. GOLDEN LAMB REST HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:336-727-9119
Mailing Address - Street 1:PO BOX 16304
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27115-6304
Mailing Address - Country:US
Mailing Address - Phone:336-727-9119
Mailing Address - Fax:336-727-1128
Practice Address - Street 1:1515 GOLDEN LAMB CT
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-6700
Practice Address - Country:US
Practice Address - Phone:336-727-9119
Practice Address - Fax:336-727-1128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-034-019310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801856Medicaid