Provider Demographics
NPI:1427866375
Name:625 ASHLAND STREET OPCO LLC
Entity type:Organization
Organization Name:625 ASHLAND STREET 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 1:625 ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:ARCHDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27263-2943
Mailing Address - Country:US
Mailing Address - Phone:336-434-2902
Mailing Address - Fax:336-434-4601
Practice Address - Street 1:625 ASHLAND ST
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-2943
Practice Address - Country:US
Practice Address - Phone:336-434-2902
Practice Address - Fax:336-434-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-24
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
NC1700821865Medicaid