Basic Information
| Provider Information | |||||||||
| NPI: | 1871628966 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RHA HEALTH SERVICES NC, LLC | ||||||||
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| OtherOrganizationName: | PENNY LANE II | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1819 PEACHTREE RD NE | ||||||||
| Address2: | STE 450 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043642900 | ||||||||
| FaxNumber: | 4043642901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2810 HIGHWAY 70 EAST | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286108527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284280061 | ||||||||
| FaxNumber: | 8284283600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | LOZANO | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 4043642900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 3416475 | 05 | NC | MEDICAID |