=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619015773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSEMONT REST HOME INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 602 GLENDALE AVE
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-6724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-318-9667
-----------------------------------------------------
Fax | 910-276-9223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2804
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28372-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-318-9667
-----------------------------------------------------
Fax | 910-276-9223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARLITA MOUJAHED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-318-9667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | HAL-078-020
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------