Provider Demographics
NPI:1447399134
Name:THE ROSSBERRY HOME OF FAIRMONT, INC.
Entity Type:Organization
Organization Name:THE ROSSBERRY HOME OF FAIRMONT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-933-3314
Mailing Address - Street 1:950 LANE ST
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-3748
Mailing Address - Country:US
Mailing Address - Phone:704-933-3314
Mailing Address - Fax:704-933-3320
Practice Address - Street 1:13178 NC HIGHWAY 130 E
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-9597
Practice Address - Country:US
Practice Address - Phone:910-628-7575
Practice Address - Fax:910-628-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL078183322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603945Medicaid