Basic Information
| Provider Information | |||||||||
| NPI: | 1649348707 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RV NURSING HOME, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RICH SQUARE VILLA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 NORTH MAIN STREET | ||||||||
| Address2: | P O BOX 560 | ||||||||
| City: | RICH SQUARE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278690560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525392011 | ||||||||
| FaxNumber: | 2525392317 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | RICH SQUARE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278690560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525392011 | ||||||||
| FaxNumber: | 2525392317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 08/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2522096834 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RV NURSING HOME LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-066-010 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.