Basic Information
| Provider Information | |||||||||
| NPI: | 1730192238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINTON HOLDINGS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLINTON HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 495 ZION HILL RD | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287526304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287383053 | ||||||||
| FaxNumber: | 8287380350 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 MARTHA LN | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283289639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105920154 | ||||||||
| FaxNumber: | 9105926361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 06/28/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TREFZGER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8283248898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-082-015 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7805562 | 05 | NC | MEDICAID |