1750508248 NPI number — HOLLY HILL HOSPITAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750508248 NPI number — HOLLY HILL HOSPITAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLY HILL HOSPITAL 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:
PSI INC OF NC DBA HOLLY HILL
Provider Other Organization Name Type Code:
4
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:
1750508248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3019 FALSTAFF RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27610-1812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-250-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 INDUSTRIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISBURG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27549-2371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-496-3444
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RYBA
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
919-250-7186

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  4724 , 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: 6102735 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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