Provider Demographics
NPI:1053553461
Name:HOLLY LANE REHABILITATION AND HEALTHCARE CENTER, LLC
Entity type:Organization
Organization Name:HOLLY LANE REHABILITATION AND HEALTHCARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:2105 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6312
Mailing Address - Country:US
Mailing Address - Phone:208-467-5721
Mailing Address - Fax:208-467-2748
Practice Address - Street 1:2105 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6312
Practice Address - Country:US
Practice Address - Phone:208-467-5721
Practice Address - Fax:208-467-2748
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORIANNA HEALTH SYSTEMS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-31
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAPPLIED FOR314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDAPPLIED FORMedicaid
135094Medicare Oscar/Certification