Basic Information
| Provider Information | |||||||||
| NPI: | 1609057165 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTPRINTS CAROLINA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 REMOUNT RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048842500 | ||||||||
| FaxNumber: | 7045242095 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 MCBEE ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLNTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280922818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047355633 | ||||||||
| FaxNumber: | 7047351924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7048842500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 5903099 | 05 | NC | MEDICAID | 8300450H | 05 | NC | MEDICAID | 8300450 | 05 | NC | MEDICAID | 8300450B | 05 | NC | MEDICAID | 6005759 | 05 | NC | MEDICAID | 8300450G | 05 | NC | MEDICAID |