MEDICARE: PIGEON VALLEY REST HOME LLC

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	311ZA0620X	Adult Care Home Facility	HAL044012	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

General Provider Information

NPI Number	:	1528051935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIGEON VALLEY REST HOME LLC

Provider Business Mailing Address
First Line	:	100 SILVER BLUFF DR
Second Line	:
City	:	CANTON
State	:	NC
Zip	:	28716-6350
Country	:	US
Telephone Number	:	828-648-2044
Fax Number	:	828-648-2065

Provider Business Practice Location Address
First Line	:	55 LAKE DR
Second Line	:
City	:	CANTON
State	:	NC
Zip	:	28716-9312
Country	:	US
Telephone Number	:	828-648-2044
Fax Number	:	828-648-2065

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. BOBBY N LEATHERWOOD
Credential	:
Telephone Number	:	828-648-2044

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	08/22/2020

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Directions to “PIGEON VALLEY REST HOME LLC ” Practice Location

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