Provider Demographics
NPI:1093799439
Name:SOUTH ROANOKE LIFE CARE, LLC
Entity Type:Organization
Organization Name:SOUTH ROANOKE LIFE CARE, LLC
Other - Org Name:SOUTH ROANOKE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER & GENERAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAINES
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:540-774-4263
Mailing Address - Street 1:3823 FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014
Mailing Address - Country:US
Mailing Address - Phone:540-344-4325
Mailing Address - Fax:540-342-0316
Practice Address - Street 1:3823 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014
Practice Address - Country:US
Practice Address - Phone:540-344-4325
Practice Address - Fax:540-342-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA49-5002314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA495002Medicare Oscar/Certification