MEDICARE: COUNTRY TIME INN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	HAL036018	NC
2	311ZA0620X	Adult Care Home Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538155643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY TIME INN LLC

Provider Business Mailing Address
First Line	:	PO BOX 2568
Second Line	:
City	:	HICKORY
State	:	NC
Zip	:	28603-2568
Country	:	US
Telephone Number	:	828-322-5535
Fax Number	:

Provider Business Practice Location Address
First Line	:	602 BREVARD ST
Second Line	:
City	:	KINGS MOUNTAIN
State	:	NC
Zip	:	28086-8692
Country	:	US
Telephone Number	:	704-739-2760
Fax Number	:	704-739-6252

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. CHARLES E TREFZGER JR.
Credential	:
Telephone Number	:	828-322-5535

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	07/28/2021

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Directions to “COUNTRY TIME INN LLC ” Practice Location

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