Provider Demographics
NPI:1861550253
Name:LISA'S FAMILY CARE HOME LLC.
Entity type:Organization
Organization Name:LISA'S FAMILY CARE HOME LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DINOVETSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-447-5523
Mailing Address - Street 1:358 SHADY WOODS LN
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-2768
Mailing Address - Country:US
Mailing Address - Phone:828-447-5523
Mailing Address - Fax:828-286-1427
Practice Address - Street 1:542 FOREST LAKE RD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-5112
Practice Address - Country:US
Practice Address - Phone:828-447-5523
Practice Address - Fax:828-286-1427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC920394Medicaid