Provider Demographics
NPI:1548494966
Name:RAINBOW 66 STOREHOUSE INC.
Entity type:Organization
Organization Name:RAINBOW 66 STOREHOUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMMIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-276-0766
Mailing Address - Street 1:525 ATKINSON ST
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-3715
Mailing Address - Country:US
Mailing Address - Phone:910-276-0766
Mailing Address - Fax:
Practice Address - Street 1:706 RIGSBEE AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2139
Practice Address - Country:US
Practice Address - Phone:919-686-0165
Practice Address - Fax:919-686-0167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-0533747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418378Medicaid