Provider Demographics
NPI:1285054593
Name:LEAKSVILLE REST HOME, LLC
Entity type:Organization
Organization Name:LEAKSVILLE REST HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER MANAGER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-280-5637
Mailing Address - Street 1:915 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5509
Mailing Address - Country:US
Mailing Address - Phone:336-280-5637
Mailing Address - Fax:336-635-9004
Practice Address - Street 1:915 IRVING AVE
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5509
Practice Address - Country:US
Practice Address - Phone:336-280-5637
Practice Address - Fax:336-635-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-079-096311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home