Basic Information
| Provider Information | |||||||||
| NPI: | 1275676561 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | B & J REST VILLA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DBA WAYNE COUNTY REST VILLA I | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 295 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278300295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192426161 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 305 SOUTH VANCE STREET | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192426161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEST | ||||||||
| AuthorizedOfficialFirstName: | LORRAINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2523151140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL 096 004 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7804062 | 05 | NC | MEDICAID |