Basic Information
Provider Information | |||||||||
NPI: | 1225224173 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINEHURST NURSING CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PINEHURST HEALTHCARE AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 09/24/2007 | ||||||||
LastUpdateDate: | 09/24/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ELLEDGE | ||||||||
AuthorizedOfficialFirstName: | NICK | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3366798852 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | NH0294 | NC | Y |   | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
ID | Type | State | Issuer | Description | 7801191 | 05 | NC |   | MEDICAID |