Provider Demographics
NPI:1447254149
Name:LUTHERAN HOME AT TRINITY OAKS, INC.
Entity type:Organization
Organization Name:LUTHERAN HOME AT TRINITY OAKS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:704-637-3784
Mailing Address - Street 1:820 KLUMAC RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-5728
Mailing Address - Country:US
Mailing Address - Phone:704-637-3784
Mailing Address - Fax:704-636-9464
Practice Address - Street 1:820 KLUMAC RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-5728
Practice Address - Country:US
Practice Address - Phone:704-637-3784
Practice Address - Fax:704-636-9464
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN SERVICES FOR THE AGING, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-09
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0197314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3415153Medicaid
NC3416124Medicaid
NC3415153Medicaid