Provider Demographics
NPI:1780688747
Name:RICH CREEK LIFE CARE, LLC
Entity Type:Organization
Organization Name:RICH CREEK LIFE CARE, LLC
Other - Org Name:HERITAGE HALL - RICH CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER & GENERAL
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAINES
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:540-774-4263
Mailing Address - Street 1:3131 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6427
Mailing Address - Country:US
Mailing Address - Phone:540-774-4263
Mailing Address - Fax:540-774-0780
Practice Address - Street 1:120 OLD VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:RICH CREEK
Practice Address - State:VA
Practice Address - Zip Code:24147-9669
Practice Address - Country:US
Practice Address - Phone:540-726-2328
Practice Address - Fax:540-726-2519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2673313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
495371Medicare ID - Type Unspecified