Basic Information
Provider Information | |||||||||
NPI: | 1164698387 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE HERITAGE OF SUGAR MOUNTAIN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 878 | ||||||||
Address2: |   | ||||||||
City: | OAK RIDGE | ||||||||
State: | NC | ||||||||
PostalCode: | 273100878 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3366430555 | ||||||||
FaxNumber: | 3366430553 | ||||||||
Practice Location | |||||||||
Address1: | 264 SUGAR MOUNTAIN | ||||||||
Address2: |   | ||||||||
City: | NEWLAND | ||||||||
State: | NC | ||||||||
PostalCode: | 286579998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8287336249 | ||||||||
FaxNumber: | 8287330358 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2008 | ||||||||
LastUpdateDate: | 06/26/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PIERCE | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | VANN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3366430555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL006005 | NC | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 311ZA0620X | HAL-006-005 | NC | Y |   | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
ID | Type | State | Issuer | Description | 7806012 | 05 | NC |   | MEDICAID |