=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780058909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSE PALMS LIGHT OF HOPE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2015
-----------------------------------------------------
Last Update Date | 11/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8116 S TRYON ST STE B3,BOX123
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28273-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-522-4195
-----------------------------------------------------
Fax | 888-854-8514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8116 S TRYON ST STE B3,BOX123
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28273-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EX. DIRECTOR
-----------------------------------------------------
Name | MR. MICHAEL BROOKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 980-822-4195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------