Basic Information
| Provider Information | |||||||||
| NPI: | 1124393962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA RESIDENTIAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 286 | ||||||||
| Address2: | |||||||||
| City: | RUTHERFORD COLLEGE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286710286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285722333 | ||||||||
| FaxNumber: | 9802250500 | ||||||||
| Practice Location | |||||||||
| Address1: | 1014 HAY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109202891 | ||||||||
| FaxNumber: | 9109202756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 03/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | KINCAID | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8284133786 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL-026-837 | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8303428S | 05 | NC | MEDICAID |