Provider Demographics
NPI:1811421456
Name:MOCKSVILLE OPCO, LLC
Entity Type:Organization
Organization Name:MOCKSVILLE OPCO, LLC
Other - Org Name:MOCKSVILLE SENIOR LIVING AND MEMORY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:TREFZGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-322-5535
Mailing Address - Street 1:337 HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2060
Mailing Address - Country:US
Mailing Address - Phone:336-751-2175
Mailing Address - Fax:336-751-0136
Practice Address - Street 1:337 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2060
Practice Address - Country:US
Practice Address - Phone:336-751-2175
Practice Address - Fax:336-751-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL030009310400000X
311ZA0620X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)