Basic Information
| Provider Information | |||||||||
| NPI: | 1265608467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE HERITAGE OF CEDAR ROCK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 878 | ||||||||
| Address2: | |||||||||
| City: | OAK RIDGE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273100878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366430555 | ||||||||
| FaxNumber: | 3366430553 | ||||||||
| Practice Location | |||||||||
| Address1: | 191 CRESTVIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOCKSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270282643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367511515 | ||||||||
| FaxNumber: | 3367511621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 06/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | VANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3366430555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL030007 | NC | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 311ZA0620X | HAL-030-007 | NC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 7806011 | 05 | NC | MEDICAID |