Basic Information
Provider Information | |||||||||
NPI: | 1619242518 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAROLINA RESIDENTIAL SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 286 | ||||||||
Address2: |   | ||||||||
City: | RUTHERFORD COLLEGE | ||||||||
State: | NC | ||||||||
PostalCode: | 286710286 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8285722333 | ||||||||
FaxNumber: | 9802250500 | ||||||||
Practice Location | |||||||||
Address1: | 714 SIMMONS ST | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 275303843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9195800020 | ||||||||
FaxNumber: | 9195800026 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2012 | ||||||||
LastUpdateDate: | 03/12/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KINCAID | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR/OWNER | ||||||||
AuthorizedOfficialTelephone: | 8284133786 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL-096-005 | NC | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 8303429S | 05 | NC |   | MEDICAID |