Provider Demographics
NPI:1902822182
Name:ROSE TARA HOLDINGS, LLC
Entity Type:Organization
Organization Name:ROSE TARA HOLDINGS, LLC
Other - Org Name:ROSE TARA PLANTATION, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
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:PO BOX 2568
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-2568
Mailing Address - Country:US
Mailing Address - Phone:828-322-5535
Mailing Address - Fax:828-322-9587
Practice Address - Street 1:125 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:KING
Practice Address - State:NC
Practice Address - Zip Code:27021-9590
Practice Address - Country:US
Practice Address - Phone:336-983-8929
Practice Address - Fax:336-983-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-085-008310400000X
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)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805465Medicaid