Basic Information
| Provider Information | |||||||||
| NPI: | 1902822182 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSE TARA HOLDINGS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROSE TARA PLANTATION, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2568 | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286032568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283225535 | ||||||||
| FaxNumber: | 8283229587 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 PLANTATION DR | ||||||||
| Address2: | |||||||||
| City: | KING | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270219590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369838929 | ||||||||
| FaxNumber: | 3369837424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TREFZGER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8283225535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 343900000X | N | Transportation Services | Non-emergency Medical Transport (VAN) | 310400000X | HAL-085-008 | NC | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 311ZA0620X | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 7805465 | 05 | NC | MEDICAID |