Provider Demographics
NPI:1962435149
Name:SALEM HOUSING CORPORATION
Entity type:Organization
Organization Name:SALEM HOUSING CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF MGMT CO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:MITTLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-619-0866
Mailing Address - Street 1:5895 WINDWARD PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5203
Mailing Address - Country:US
Mailing Address - Phone:770-619-0866
Mailing Address - Fax:770-870-2892
Practice Address - Street 1:315 W GIBSON ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4903
Practice Address - Country:US
Practice Address - Phone:409-384-5768
Practice Address - Fax:409-383-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116446314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013913Medicaid
67-5709Medicare ID - Type Unspecified