Raven Lake Healthcare, Inc.

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

RAVEN LAKE HEALTHCARE, INC.

Doing business as

TriState Health and Rehabilitation Center

Practice address

600 Shawanee Rd
Harrogate, TN 37752-8305

Phone

(423) 869-5376

Fax

(423) 869-4107

NPI assigned

Nov 8, 2023

Last updated

Aug 30, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Soon Burnam

Title

Treasurer

Phone

(949) 540-1249

Specialties & licenses 1

Addresses

Other names 1

• TriState Health and Rehabilitation Center Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in TN

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1285408401. Details of each certification follow.

• CCN 445263 Skilled nursing facility · Active · Details

Skilled nursing facility certification: CCN 445263

Legal name

RAVEN LAKE HEALTHCARE INC

Doing business as

TRISTATE HEALTH AND REHABILITATION CENTER

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Mar 21, 1991

Last certification

Aug 16, 2023

Beds

116

Ownership / control type

Corporation

Multi-facility organization

ENSIGN

Organization structure

CorporationProprietary

Incorporated

Oct 17, 2023 in NV

Enrollment address

600 Shawanee Rd
Harrogate, TN 37752-8305

Nursing home name

TRI STATE HEALTH AND REHABILITATION CENTER

Affiliated entity

THE ENSIGN GROUP

Listed as

Tri State Health and Rehabilitation CenterCCN 445263 · All quality measures

Overall star rating

1 of 5

Health inspections

1 of 5

Staffing

2 of 5

Quality measures

3 of 5

Type

Medicare and Medicaid

Ownership

For profit - Corporation

Certified

Mar 21, 1991

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

116101.3 residents per day on average

Chain

The Ensign Group342 facilities in the chain

Abuse citation

Cited for abuse (Care Compare abuse icon)

Penalties (3 years)

2Fines totaling $14,852

Processed by Care Compare on Aug 1, 2026.

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Luis C Pannocchia, M.D.

  • Family Medicine Physician
  • New Tazewell, TN
  • NPI 1912988965

  Adp of the SNF

  CMS ownership

Facilities with the same owner 8

Facilities that share an organizational owner with 5% or greater ownership or operational control.

• Bear Creek Healthcare LLC

  • Skilled Nursing Facility
  • Parsons, TN
  • NPI 1912732249

  Rocky Top Healthcare LLC

  CMS ownership
• Big Creek Healthcare, Inc.

  • Skilled Nursing Facility
  • Pulaski, TN
  • NPI 1033944350

  Rocky Top Healthcare LLC

  CMS ownership
• Black Wolf Healthcare LLC

  • Skilled Nursing Facility
  • Decaturville, TN
  • NPI 1447085782

  Rocky Top Healthcare LLC

  CMS ownership
• Cane Creek Healthcare, Inc.

  • Skilled Nursing Facility
  • Martin, TN
  • NPI 1235964560

  Rocky Top Healthcare LLC

  CMS ownership
• First Creek Healthcare, Inc.

  dba Creekview Health and Rehabilitation

  • Skilled Nursing Facility
  • Knoxville, TN
  • NPI 1639949704

  Rocky Top Healthcare LLC

  CMS ownership
• Lacefield Healthcare LLC

  • Skilled Nursing Facility
  • Savannah, TN
  • NPI 1992530232

  Rocky Top Healthcare LLC

  CMS ownership
• Smoky Mountain Healthcare, Inc.

  dba Foothills Transitional Care and Rehabilitation

  • Skilled Nursing Facility
  • Maryville, TN
  • NPI 1447020516

  Rocky Top Healthcare LLC

  CMS ownership
• Turner Healthcare, Inc.

  • Skilled Nursing Facility
  • Union City, TN
  • NPI 1669207999

  Rocky Top Healthcare LLC

  CMS ownership

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Luis C Pannocchia, M.D.

  • Family Medicine Physician
  • New Tazewell, TN
  • NPI 1912988965
  NPD (past)

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

• Luis C Pannocchia, M.D.

  • Family Medicine Physician
  • New Tazewell, TN
  • NPI 1912988965

  Nursing home

  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1699401600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724976000000",
    "number": "1285408401",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "600 SHAWANEE RD",
            "city": "HARROGATE",
            "state": "TN",
            "postal_code": "377528305",
            "telephone_number": "423-869-5376",
            "fax_number": "423-869-4107"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 SHAWANEE RD",
            "city": "HARROGATE",
            "state": "TN",
            "postal_code": "377528305",
            "telephone_number": "423-869-5376",
            "fax_number": "423-869-4107"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RAVEN LAKE HEALTHCARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-11-08",
        "last_updated": "2024-08-30",
        "certification_date": "2024-08-30",
        "status": "A",
        "authorized_official_last_name": "BURNAM",
        "authorized_official_first_name": "SOON",
        "authorized_official_title_or_position": "TREASURER",
        "authorized_official_telephone_number": "949-540-1249"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0NhinService/XDRReesponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1066.1",
            "affiliationName": "eSolutions Inc.",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CSV",
            "address_1": "8215 W 108th Ter",
            "city": "Overland Park",
            "state": "KS",
            "country_code": "US",
            "postal_code": "662101661",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "TriState Health and Rehabilitation Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Pinnacle Performance Physical Therapy LLC (Pinnacle Performance Physical Therapy)
• Debbie A Poore, FNP
• Psychiatric Practice,LLC
• Ashley Nicole Puzon
• Ramesh Kadekoppal Rao, MD
• Julianne Christine Ray
• Lucas Alexander Rice
• John M Robertson, MD
• Sherri J Robertson, APRN
• Matthew Robinson

• Skilled Nursing Facility in Harrogate, TN
• Providers in Harrogate, TN by specialty
• Skilled Nursing Facility in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 30, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.