Provider Demographics
NPI:1780693663
Name:PENICK VILLAGE INC
Entity type:Organization
Organization Name:PENICK VILLAGE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-692-0434
Mailing Address - Street 1:401 E RHODE ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-4009
Mailing Address - Country:US
Mailing Address - Phone:910-692-0300
Mailing Address - Fax:910-692-5509
Practice Address - Street 1:401 E RHODE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-4009
Practice Address - Country:US
Practice Address - Phone:910-692-0300
Practice Address - Fax:910-692-5509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0127314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405111Medicaid
NC345111OtherMEDICARE SKILLED NURSING
NC3406353Medicaid