Basic Information
| Provider Information | |||||||||
| NPI: | 1578794566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT PLACE OF SOUTH PARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 RUNNYMEDE LN | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045255508 | ||||||||
| FaxNumber: | 7045252672 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 RUNNYMEDE LN | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045255508 | ||||||||
| FaxNumber: | 7045252672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2009 | ||||||||
| LastUpdateDate: | 08/07/2009 | ||||||||
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| AuthorizedOfficialLastName: | ANTHONY | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
| AuthorizedOfficialMiddleName: | HICKSON | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7046891406 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL-060-096 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7806173 | 05 | NC | MEDICAID |