Basic Information
| Provider Information | |||||||||
| NPI: | 1053423913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINDRED NURSING CENTERS EAST, L.L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KINDRED TRANSITIONAL CARE AND REHABILITATION-ELIZABETH CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 S. FOURTH ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025966505 | ||||||||
| FaxNumber: | 5025964134 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 HALSTEAD BLVD | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279096920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523380137 | ||||||||
| FaxNumber: | 2523382745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5025967563 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0302 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3435184 & 3426247 | 05 | NC | MEDICAID | 0084G | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |