Provider Demographics
NPI:1144646274
Name:PETTIGREW REHABILITATION CENTER, LLC
Entity type:Organization
Organization Name:PETTIGREW REHABILITATION CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:R.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CRONQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-574-2100
Mailing Address - Street 1:5887 GLENRIDGE DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5574
Mailing Address - Country:US
Mailing Address - Phone:404-574-2100
Mailing Address - Fax:404-574-2105
Practice Address - Street 1:1515 W PETTIGREW ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4821
Practice Address - Country:US
Practice Address - Phone:919-286-0751
Practice Address - Fax:919-286-7065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
NCNH0119314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1144646274Medicaid
NC1144646274Medicaid