Basic Information
| Provider Information | |||||||||
| NPI: | 1578639654 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIAN RIVER RESIDENTIAL CARE COMMUNITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DBA INDIAN RIVER RETIREMENT COMMUNITY, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1487 | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272851487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365951075 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1012 JUSTIS ST | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233252516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575234659 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | GUY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3365951075 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | VA | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 5002281 | 05 | VA | MEDICAID |