Provider Demographics
NPI:1194871483
Name:ROSE OF SHARON ADOLESCENT TREATMENT HOME
Entity type:Organization
Organization Name:ROSE OF SHARON ADOLESCENT TREATMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:W
Authorized Official - Last Name:PETTIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-550-2648
Mailing Address - Street 1:161 KENTUCKY DERBY DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-6080
Mailing Address - Country:US
Mailing Address - Phone:919-550-2648
Mailing Address - Fax:919-220-1185
Practice Address - Street 1:13 RHYN CT
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2359
Practice Address - Country:US
Practice Address - Phone:919-220-2492
Practice Address - Fax:919-550-2648
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSE OF SHARON ADOLESCENT TREATMENT HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-27
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 032275322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603291Medicaid