Basic Information
| Provider Information | |||||||||
| NPI: | 1568708238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WP-BREVARD HEALTH HOLDINGS I, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CEDAR MOUNTAIN HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2568 | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286032568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283225535 | ||||||||
| FaxNumber: | 8283268115 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 SHERWOOD RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287126538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288849510 | ||||||||
| FaxNumber: | 8288843920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2012 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TREFZGER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8283225535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-088-014 | NC | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 343900000X | N | Transportation Services | Non-emergency Medical Transport (VAN) | 311ZA0620X | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
No ID Information.