Basic Information
| Provider Information | |||||||||
| NPI: | 1326181827 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA RESIDENTIAL SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 286 | ||||||||
| Address2: | |||||||||
| City: | RUTHERFORD COLLEGE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286710286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285722333 | ||||||||
| FaxNumber: | 9802250385 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 CHERRY STREET | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278970717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525873276 | ||||||||
| FaxNumber: | 2525873278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 11/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | KINCAID | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8285722333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | MHL-066-003 | NC | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 7804229 | 05 | NC | MEDICAID |