Provider Demographics
NPI:1336216779
Name:RV NURSING HOME, LLC
Entity Type:Organization
Organization Name:RV NURSING HOME, LLC
Other - Org Name:RICH SQUARE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:252-209-6834
Mailing Address - Street 1:320 NORTH MAIN STREET
Mailing Address - Street 2:P O BOX 560
Mailing Address - City:RICH SQUARE
Mailing Address - State:NC
Mailing Address - Zip Code:27869-0560
Mailing Address - Country:US
Mailing Address - Phone:252-539-4161
Mailing Address - Fax:252-539-4361
Practice Address - Street 1:320 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:RICH SQUARE
Practice Address - State:NC
Practice Address - Zip Code:27869-0560
Practice Address - Country:US
Practice Address - Phone:252-539-4161
Practice Address - Fax:252-539-4361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0045314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC923433OtherFACILITY ID NUMBER
NC3425356Medicaid
NC3426020Medicaid
NC923433OtherFACILITY ID NUMBER