1194871483 NPI number — ROSE OF SHARON ADOLESCENT TREATMENT HOME

Table of content: PAMELA IRENE JEFFRIES NP (NPI 1437594918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194871483 NPI number — ROSE OF SHARON ADOLESCENT TREATMENT HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSE OF SHARON ADOLESCENT TREATMENT HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194871483
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
161 KENTUCKY DERBY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAYTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27520-6080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-550-2648
Provider Business Mailing Address Fax Number:
919-220-1185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13 RHYN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27704-2359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-220-2492
Provider Business Practice Location Address Fax Number:
919-550-2648
Provider Enumeration Date:
01/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PETTIFORD
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CEO-OWNER
Authorized Official Telephone Number:
919-550-2648

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  MHL 032275 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6603291 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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