Provider Demographics
NPI:1417157975
Name:CRANBERRY HOUSE, LLC
Entity Type:Organization
Organization Name:CRANBERRY HOUSE, LLC
Other - Org Name:CRANBERRY HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:MANANGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:TREFZGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:828-322-5535
Mailing Address - Street 1:1978 8TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3312
Mailing Address - Country:US
Mailing Address - Phone:828-322-5535
Mailing Address - Fax:
Practice Address - Street 1:6215 US 19E
Practice Address - Street 2:
Practice Address - City:ELK PARK
Practice Address - State:NC
Practice Address - Zip Code:28622
Practice Address - Country:US
Practice Address - Phone:828-733-5558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-006-004311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805864Medicaid