Basic Information
| Provider Information | |||||||||
| NPI: | 1053370833 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGINALD L. HARRIS ANNEX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275734629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365992121 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275734629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365992121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JAMES | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 3365992121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | H0066 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3405004 | 05 | NC | MEDICAID | 00904 | 01 | NC | BLUE CROSS PROVIDER # | OTHER | 3496588 | 05 | NC | MEDICAID |