Basic Information
| Provider Information | |||||||||
| NPI: | 1225019409 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINEVILLE REHABILITATION AND LIVING | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PINEVILLE REHABILITATION AND LIVING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 LAKEVIEW DR | ||||||||
| Address2: | |||||||||
| City: | PINEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281347567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048892273 | ||||||||
| FaxNumber: | 7048892010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 LAKEVIEW DR | ||||||||
| Address2: | |||||||||
| City: | PINEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281347567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048892273 | ||||||||
| FaxNumber: | 7048892010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 02/26/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAF | ||||||||
| AuthorizedOfficialFirstName: | MARCELLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2243772400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0521 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 340601G | 05 | NC | MEDICAID | 3405415 | 05 | NC | MEDICAID |