Basic Information
| Provider Information | |||||||||
| NPI: | 1336142470 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HILLCREST CONVALESCENT CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1417 W PETTIGREW ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277054820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192867705 | ||||||||
| FaxNumber: | 9192863772 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 W PETTIGREW ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277054820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192867705 | ||||||||
| FaxNumber: | 9192863772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | TED | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9192867705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | NHA | ||||||||
| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | NH0038 | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 314000000X | NH0038 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3496052 | 05 | NC | MEDICAID | 3405001 | 01 | NC | SKILLED MEDICAID | OTHER |