Provider Demographics
NPI:1326171893
Name:PEN-DU REST HOME
Entity Type:Organization
Organization Name:PEN-DU REST HOME
Other - Org Name:HOME FOR THE AGED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LEVOISE
Authorized Official - Middle Name:BOND
Authorized Official - Last Name:ENGLISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-259-4469
Mailing Address - Street 1:685 NC HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-9316
Mailing Address - Country:US
Mailing Address - Phone:910-259-4469
Mailing Address - Fax:910-259-3844
Practice Address - Street 1:685 NC HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-9316
Practice Address - Country:US
Practice Address - Phone:910-259-4469
Practice Address - Fax:910-259-3844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-071-001311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802025Medicaid