Provider Demographics
NPI:1730175985
Name:CANTON CHRISTIAN CONVALESCENT CENTER, LLC
Entity type:Organization
Organization Name:CANTON CHRISTIAN CONVALESCENT CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:75 FISHER LOOP
Mailing Address - Street 2:
Mailing Address - City:MAGGIE VALLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28751-5531
Mailing Address - Country:US
Mailing Address - Phone:828-566-3002
Mailing Address - Fax:828-648-3551
Practice Address - Street 1:75 FISHER LOOP
Practice Address - Street 2:
Practice Address - City:MAGGIE VALLEY
Practice Address - State:NC
Practice Address - Zip Code:28751-5531
Practice Address - Country:US
Practice Address - Phone:828-566-3002
Practice Address - Fax:828-648-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0081314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3435358Medicaid
NC3445102Medicaid
NC3435358Medicaid