MEDICARE: PREMIER LIVING AND REHAB CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BN1400X	Nursing Facility Supplies (DME)	5030990001	NC
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	5030990001	NC
3	314000000X	Skilled Nursing Facility	NH0246	NC
4	313M00000X	Nursing Facility/Intermediate Care Facility		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720085293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER LIVING AND REHAB CENTER

Provider Business Mailing Address
First Line	:	106 CAMERON ST
Second Line	:
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-1900
Country	:	US
Telephone Number	:	910-646-3132
Fax Number	:	910-646-4071

Provider Business Practice Location Address
First Line	:	106 CAMERON ST
Second Line	:
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-1900
Country	:	US
Telephone Number	:	910-646-3132
Fax Number	:	910-646-4071

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. LINDA BENTON PARNELL
Credential	:	LNHA
Telephone Number	:	910-646-3132

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	11/02/2011

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1366517872 — MS. TERESA B HOPKINS FNP
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1366593170 — MR. EUGENE GLENN BROWN JR. RPH
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