=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801147186
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKILL CREATIONS OF KENANSVILLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2012
-----------------------------------------------------
Last Update Date | 01/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 218 S STOKES STREET
-----------------------------------------------------
City | KENANSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28349-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-296-0078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1636
-----------------------------------------------------
City | GOLDSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27533-1636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-734-7398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | PAUL HACKMANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-734-7398
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | MHL-031-004
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | MHL-031-004
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------