# NC DEPT OF MILTARY AND VETERANS AFFAIRS NC DIVISION OF VETERAN AFF

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- **Entity:** Organization
- **Status:** Active
- **Other names:** NC STATE VETERANS HOME - BLACK MTN
- **Organization subpart:** No

## Provider details

- **NPI number:** 1578814588
- **Authorized official:** LYNETHIA N HOLLEY (PROVIDER ENROLLMENT SPEC)
- **Authorized official phone:** (770) 806-6875

## Contact information

- **Practice address:** 62 LAKE EDEN ROAD, BLACK MOUNTAIN, NC 28711-8706
- **Practice address phone:** (828) 257-6800
- **Practice address fax:** (919) 807-4266
- **Mailing address:** 4001 MAIL SERVICE CENTER, RALEIGH, NC 27699-4000
- **Mailing address phone:** (828) 257-6800
- **Mailing address fax:** (984) 204-8344

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | NH0631 | NC | Yes |

## Other

- **Enumeration date:** 10/01/2012
- **Last updated:** 07/24/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | NH0631 | STATE OF NORTH CAROLINA LICENSURE - | NC |