Basic Information
| Provider Information | |||||||||
| NPI: | 1639556806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HILLCREST RALEIGH AT CRABTREE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HILLCREST RALEIGH AT CRABTREE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 3830 BLUE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276124319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197814900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2015 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOOVER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | HEFFNER | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9192867705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HILLCREST CONVALESCENT CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0428 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3405555 | 05 | NC | MEDICAID |