Basic Information
| Provider Information | |||||||||
| NPI: | 1285796284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RHA HEALTH SERVICES NC, LLC | ||||||||
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| OtherOrganizationName: | GATEWOOD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1819 PEACHTREE RD NE | ||||||||
| Address2: | STE 450 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043642900 | ||||||||
| FaxNumber: | 4043642901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1508 GATEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274056816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362736105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 09/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | LOZANO | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 4049682663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | MHL-041-055 | NC | N | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities | 315P00000X | MHL-041-055 | NC | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 3416471 | 05 | NC | MEDICAID |