Basic Information
| Provider Information | |||||||||
| NPI: | 1689926107 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAYETTEVILLE AL HOLDINGS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERTIAGE SUITES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2568 | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286032568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282617304 | ||||||||
| FaxNumber: | 8283224538 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 ANN ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283015543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103234925 | ||||||||
| FaxNumber: | 9106788673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2012 | ||||||||
| LastUpdateDate: | 10/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | TREFZGER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8282617309 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-026-061 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.