=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598014987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHELBY AL HOLDINGS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2012
-----------------------------------------------------
Last Update Date | 08/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 HARDIN DR
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28150-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-480-9800
-----------------------------------------------------
Fax | 704-480-9803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 SPRING ST SUTIE 205
-----------------------------------------------------
City | SILVER SPRINGS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20910-3654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-841-2919
-----------------------------------------------------
Fax | 240-841-2630
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | CHARLES TREFZGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-261-7309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | HAL-023-044
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------