Provider Demographics
NPI:1720085293
Name:PREMIER LIVING AND REHAB CENTER
Entity Type:Organization
Organization Name:PREMIER LIVING AND REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:BENTON
Authorized Official - Last Name:PARNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:910-646-3132
Mailing Address - Street 1:106 CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WACCAMAW
Mailing Address - State:NC
Mailing Address - Zip Code:28450-1900
Mailing Address - Country:US
Mailing Address - Phone:910-646-3132
Mailing Address - Fax:910-646-4071
Practice Address - Street 1:106 CAMERON ST
Practice Address - Street 2:
Practice Address - City:LAKE WACCAMAW
Practice Address - State:NC
Practice Address - Zip Code:28450-1900
Practice Address - Country:US
Practice Address - Phone:910-646-3132
Practice Address - Fax:910-646-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC313M00000X
NCNH0246314000000X
NC5030990001332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3435185Medicaid
NC3436171Medicaid
NC7804320Medicaid
NC5030990001Medicare NSC
NC7804320Medicaid