Provider Demographics
NPI:1831372804
Name:COMMONWOOD HOME
Entity type:Organization
Organization Name:COMMONWOOD HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-453-0367
Mailing Address - Street 1:348 LEONARD LANE
Mailing Address - Street 2:
Mailing Address - City:ELLENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28040
Mailing Address - Country:US
Mailing Address - Phone:828-453-0367
Mailing Address - Fax:828-453-0367
Practice Address - Street 1:348 LEONARD LANE
Practice Address - Street 2:
Practice Address - City:ELLENBORO
Practice Address - State:NC
Practice Address - Zip Code:28040
Practice Address - Country:US
Practice Address - Phone:828-453-0367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-081-0263104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804158Medicaid