Provider Demographics
NPI:1689777971
Name:SSC KENANSVILLE OPERATING COMPANY LLC
Entity Type:Organization
Organization Name:SSC KENANSVILLE OPERATING COMPANY LLC
Other - Org Name:KENANSVILLE HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP OPERATIONS FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-443-7000
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5161
Mailing Address - Country:US
Mailing Address - Phone:832-467-6000
Mailing Address - Fax:
Practice Address - Street 1:209 BEASLEY STREET
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349
Practice Address - Country:US
Practice Address - Phone:910-296-1561
Practice Address - Fax:910-296-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0308314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3445150Medicaid
NC345150Medicare Oscar/Certification