Provider Demographics
NPI:1902083801
Name:ROSA BRADLEY'S HOME FOR ADULTS,LLC
Entity Type:Organization
Organization Name:ROSA BRADLEY'S HOME FOR ADULTS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:SHERARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-752-3237
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-0819
Mailing Address - Country:US
Mailing Address - Phone:252-752-3237
Mailing Address - Fax:
Practice Address - Street 1:2215 NORTH MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5026
Practice Address - Country:US
Practice Address - Phone:252-752-3237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-074-035310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility