Provider Demographics
NPI:1164698387
Name:THE HERITAGE OF SUGAR MOUNTAIN
Entity Type:Organization
Organization Name:THE HERITAGE OF SUGAR MOUNTAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:VANN
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-643-0555
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:27310-0878
Mailing Address - Country:US
Mailing Address - Phone:336-643-0555
Mailing Address - Fax:336-643-0553
Practice Address - Street 1:264 SUGAR MOUNTAIN
Practice Address - Street 2:
Practice Address - City:NEWLAND
Practice Address - State:NC
Practice Address - Zip Code:28657-9998
Practice Address - Country:US
Practice Address - Phone:828-733-6249
Practice Address - Fax:828-733-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL006005310400000X
NCHAL-006-005311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7806012Medicaid