Provider Demographics
NPI:1689796278
Name:LEAKSVILLE REST HOME #2
Entity Type:Organization
Organization Name:LEAKSVILLE REST HOME #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-623-5700
Mailing Address - Street 1:914 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5510
Mailing Address - Country:US
Mailing Address - Phone:336-623-5700
Mailing Address - Fax:336-623-5708
Practice Address - Street 1:914 IRVING AVE
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5510
Practice Address - Country:US
Practice Address - Phone:336-623-5700
Practice Address - Fax:336-623-5708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility