Basic Information
| Provider Information | |||||||||
| NPI: | 1548572357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAINTREE HEALTHCARE OF KANNAPOLIS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KANNAPOLIS VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2015 AYRSLEY TOWN BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282734068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042808340 | ||||||||
| FaxNumber: | 7049734019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1516 PINE ST | ||||||||
| Address2: | |||||||||
| City: | KANNAPOLIS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280814142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042808340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2010 | ||||||||
| LastUpdateDate: | 07/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | OWENS | ||||||||
| AuthorizedOfficialFirstName: | REEMA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7047636300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.