Basic Information
| Provider Information | |||||||||
| NPI: | 1962731935 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BREVARD SOUTH OPERATING AL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CEDAR MOUNTAIN HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2568 | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286032568 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 SHERWOOD RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287126558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288849510 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2009 | ||||||||
| LastUpdateDate: | 12/21/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TREFZGER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8282617312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.