Basic Information
| Provider Information | |||||||||
| NPI: | 1407999212 | ||||||||
| 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: | 9802250500 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286773550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285722333 | ||||||||
| FaxNumber: | 9802250500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 09/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | KINCAID | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8285722333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 09/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | N | Agencies | In Home Supportive Care | 311ZA0620X | N | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3409122 | 05 | NC | MEDICAID | 3419151 | 05 | NC | MEDICAID |