Basic Information
| Provider Information | |||||||||
| NPI: | 1760682579 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDENTON HOUSE, LLC | ||||||||
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| OtherOrganizationName: | EDENTON HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1978 8TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286013312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283225535 | ||||||||
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| Practice Location | |||||||||
| Address1: | 323 MEDICAL ARTS DRIVE | ||||||||
| Address2: | |||||||||
| City: | EDENTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524821113 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | TREFZGER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8283225535 | ||||||||
| 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-021-006 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7805865 | 05 | NC | MEDICAID |