Provider Demographics
NPI:1104656511
Name:AUTHENTIC LOVE ROSE LLC
Entity type:Organization
Organization Name:AUTHENTIC LOVE ROSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANICHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-322-4506
Mailing Address - Street 1:505 MANN ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-6237
Mailing Address - Country:US
Mailing Address - Phone:910-322-4506
Mailing Address - Fax:
Practice Address - Street 1:2007 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4163
Practice Address - Country:US
Practice Address - Phone:910-322-4506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care