Provider Demographics
NPI:1376625814
Name:RAINBOW 66 STOREHOUSE, INC.
Entity Type:Organization
Organization Name:RAINBOW 66 STOREHOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMMIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-276-0766
Mailing Address - Street 1:525 ATKINSON ST
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-3715
Mailing Address - Country:US
Mailing Address - Phone:910-276-0766
Mailing Address - Fax:910-277-6295
Practice Address - Street 1:525 ATKINSON ST
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-3715
Practice Address - Country:US
Practice Address - Phone:910-276-0766
Practice Address - Fax:910-277-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC 2475251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804558Medicaid
NC6601037Medicaid
NC3418378Medicaid
NC3409455Medicaid
NC8302212Medicaid