Healthcare Provider Details

I. General information

NPI: 1790372605
Provider Name (Legal Business Name): CRDEN ROSE HOLDING COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2020
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3118 ROBERTA RD
CONCORD NC
28027-9080
US

IV. Provider business mailing address

3118 ROBERTA RD
CONCORD NC
28027-9080
US

V. Phone/Fax

Practice location:
  • Phone: 704-965-1054
  • Fax: 352-554-5073
Mailing address:
  • Phone: 704-965-1054
  • Fax: 352-554-5073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: LA TOYA DAWSON
Title or Position: BILLING DIRECTOR
Credential:
Phone: 352-231-7551