Provider Demographics
NPI:1124031349
Name:SCI - ROANOKE HOUSE
Entity Type:Organization
Organization Name:SCI - ROANOKE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-734-7398
Mailing Address - Street 1:PO BOX 1636
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27533-1636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 CLEARFIELD DR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-3327
Practice Address - Country:US
Practice Address - Phone:252-308-0902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SKILL CREATIONS INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-15
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
313M00000X
NCMHL-042-015315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406133Medicaid
NC3406234Medicaid
NC3406361Medicaid
NC3406416Medicaid
NC340605GMedicaid
NC3406243Medicaid
NC3406347Medicaid
NC3416197Medicaid
NC340603TMedicaid
NC3406250Medicaid
NC3406425Medicaid
NC3406401Medicaid
NC3406065Medicaid
NC3406339Medicaid
NC3406386Medicaid
NC3406370Medicaid
NC340605GMedicaid