1194845172 NPI number — SSC STATESVILLE BRIAN CENTER OPERATING COMPANY LLC

Table of content: (NPI 1194845172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194845172 NPI number — SSC STATESVILLE BRIAN CENTER OPERATING COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SSC STATESVILLE BRIAN CENTER OPERATING COMPANY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BRIAN CENTER HEALTH & REHABILITATION - STATESVILLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194845172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 W SAM HOUSTON PKWY N
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77041-5161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-467-6000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 VALLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28677-7935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-873-0517
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANTORO
Authorized Official First Name:
KELLE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
SR DIRECTOR AR
Authorized Official Telephone Number:
832-467-5728

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X , with the licence number:  NH0176 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X , with the licence number: NH0176 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: NH0176 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7805464 . This is a "MEDICAID REST HOME" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3436068 . This is a "MEDICAID ICF" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3435128 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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