# LEAKSVILLE REST HOME, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1285054593
- **Authorized official:** PAMELA ARTHUR CLARK (SOLE MEMBER MANAGER/ADMINISTRATOR)
- **Authorized official phone:** (336) 280-5637

## Contact information

- **Practice address:** 915 IRVING AVE, EDEN, NC 27288-5509
- **Practice address phone:** (336) 280-5637
- **Practice address fax:** (336) 635-9004
- **Mailing address:** 915 IRVING AVE, EDEN, NC 27288-5509
- **Mailing address phone:** (336) 280-5637
- **Mailing address fax:** (336) 635-9004

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 311ZA0620X | Adult Care Home Facility | FCL-079-096 | NC | Yes |

## Other

- **Enumeration date:** 04/25/2014
- **Last updated:** 04/25/2014