Provider Demographics
NPI:1952637878
Name:RAINBOW 66 STOREHOUSE INC.
Entity Type:Organization
Organization Name:RAINBOW 66 STOREHOUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
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:910-361-4398
Mailing Address - Street 1:1225 S CALEDONIA RD
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-4849
Mailing Address - Country:US
Mailing Address - Phone:910-361-4398
Mailing Address - Fax:910-361-4510
Practice Address - Street 1:1225 S CALEDONIA RD
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-4849
Practice Address - Country:US
Practice Address - Phone:910-361-4398
Practice Address - Fax:910-361-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-28
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
NCMHL-032-0533747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601037Medicaid
NC3418378Medicaid
NC3409455Medicaid
NC8302212Medicaid