Healthcare Provider Details

I. General information

NPI: 1902822182
Provider Name (Legal Business Name): ROSE TARA HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PLANTATION DR
KING NC
27021-9590
US

IV. Provider business mailing address

PO BOX 2568
HICKORY NC
28603-2568
US

V. Phone/Fax

Practice location:
  • Phone: 336-983-8929
  • Fax: 336-983-7424
Mailing address:
  • Phone: 828-322-5535
  • Fax: 828-322-9587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL-085-008
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7805465
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MR. CHARLES E TREFZGER JR.
Title or Position: MANAGER
Credential:
Phone: 828-322-5535