Basic Information
| Provider Information | |||||||||
| NPI: | 1205803137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINEHURST NURSING CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PINEHURST HEALTHCARE AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5309 | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283745309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102956158 | ||||||||
| FaxNumber: | 9102956783 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BLAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102956158 | ||||||||
| FaxNumber: | 9102956783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 09/04/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELLEDGE | ||||||||
| AuthorizedOfficialFirstName: | NICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3366798852 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0294 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0091R | 01 | NC | BCBS PROVIDER NO | OTHER | 3405370 | 05 | NC | MEDICAID | 3406228 | 05 | NC | MEDICAID |