Provider Demographics
NPI:1538285507
Name:BETTY G WELLMON
Entity type:Organization
Organization Name:BETTY G WELLMON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-538-8855
Mailing Address - Street 1:630 SUGAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:NC
Mailing Address - Zip Code:28090-9493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:628 SUGAR HILL RD
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:NC
Practice Address - Zip Code:28090-9493
Practice Address - Country:US
Practice Address - Phone:704-538-8855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL 023-002310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802405Medicaid