MEDICARE: FAYETTEVILLE AL HOLDINGS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	HAL-026-061	NC

General Provider Information

NPI Number	:	1689926107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTEVILLE AL HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2568
Second Line	:
City	:	HICKORY
State	:	NC
Zip	:	28603-2568
Country	:	US
Telephone Number	:	828-261-7304
Fax Number	:	828-322-4538

Provider Business Practice Location Address
First Line	:	240 ANN ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5543
Country	:	US
Telephone Number	:	910-323-4925
Fax Number	:	910-678-8673

Authorized Official
Title or Position	:	MANAGER
Name	:	CHARLES TREFZGER
Credential	:
Telephone Number	:	828-261-7309

Provider Enumeration Date	:	10/08/2012
Last Update Date	:	10/08/2012

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