Basic Information
| Provider Information | |||||||||
| NPI: | 1881724342 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREMONT REST CENTER | ||||||||
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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: | 300 SOUTH STREET | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192426161 | ||||||||
| FaxNumber: | 9192425187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3366430555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-096-024 | NC | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 311ZA0620X | HAL-096-024 | NC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 7804344 | 05 | NC | MEDICAID |