Provider Demographics
NPI:1811984925
Name:HILLSIDE NURSING CENTER OF WAKE FOREST, INC.
Entity type:Organization
Organization Name:HILLSIDE NURSING CENTER OF WAKE FOREST, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-556-4082
Mailing Address - Street 1:968 WAIT AVE
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-7670
Mailing Address - Country:US
Mailing Address - Phone:919-556-4082
Mailing Address - Fax:919-554-4650
Practice Address - Street 1:968 WAIT AVE
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7670
Practice Address - Country:US
Practice Address - Phone:919-556-4082
Practice Address - Fax:919-554-4650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0525314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405417Medicaid
NC340601HMedicaid
NC7802250Medicaid
NC3405417Medicaid
NC7802250Medicaid