Provider Demographics
NPI:1699886085
Name:HIGHLAND HOUSE OF FAYETTEVILLE, INC
Entity type:Organization
Organization Name:HIGHLAND HOUSE OF FAYETTEVILLE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-998-5001
Mailing Address - Street 1:1700 PAMALEE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-2824
Mailing Address - Country:US
Mailing Address - Phone:910-488-2295
Mailing Address - Fax:910-488-0087
Practice Address - Street 1:1700 PAMALEE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-2824
Practice Address - Country:US
Practice Address - Phone:910-488-2295
Practice Address - Fax:910-488-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0117314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405353Medicaid
NC3406055Medicaid
NC7801640Medicaid
NC3405353Medicaid