Healthcare Provider Details

I. General information

NPI: 1598014987
Provider Name (Legal Business Name): SHELBY AL HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 HARDIN DR
SHELBY NC
28150-3500
US

IV. Provider business mailing address

1300 SPRING ST SUTIE 205
SILVER SPRINGS MD
20910-3654
US

V. Phone/Fax

Practice location:
  • Phone: 704-480-9800
  • Fax: 704-480-9803
Mailing address:
  • Phone: 240-841-2919
  • Fax: 240-841-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL-023-044
License Number StateNC

VIII. Authorized Official

Name: CHARLES TREFZGER
Title or Position: MANAGER
Credential:
Phone: 828-261-7309