Healthcare Provider Details

I. General information

NPI: 1548192073
Provider Name (Legal Business Name): ROSEBUD HEADQUATERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SANDY CT
KANNAPOLIS NC
28083-8036
US

IV. Provider business mailing address

200 S BOSTIAN ST
CHINA GROVE NC
28023-2438
US

V. Phone/Fax

Practice location:
  • Phone: 980-334-1319
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: TAYHA BLACK
Title or Position: PRESIDENT
Credential:
Phone: 980-334-1319