Basic Information
| Provider Information | |||||||||
| NPI: | 1942847157 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIGO HALL OPERATING CO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2568 | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286032568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282700651 | ||||||||
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| Practice Location | |||||||||
| Address1: | 509 STANDARD WAY | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294122397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434064747 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2019 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | TREFZGER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8283225535 | ||||||||
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| 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 | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.