Provider Demographics
NPI:1740278126
Name:SENIOR CITIZENS HOME INC
Entity type:Organization
Organization Name:SENIOR CITIZENS HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:252-492-0066
Mailing Address - Street 1:2275 RUIN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27537-8732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2275 RUIN CREEK RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27537-8732
Practice Address - Country:US
Practice Address - Phone:252-492-0066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0477310400000X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406558Medicaid
NC7801016Medicaid
NC3405316Medicaid
NC3405316Medicaid