Basic Information
| Provider Information | |||||||||
| NPI: | 1699827121 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONARCH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 350 PEE DEE AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280014945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049861522 | ||||||||
| FaxNumber: | 7049825279 | ||||||||
| Practice Location | |||||||||
| Address1: | 1617 MOSS SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280017820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049825882 | ||||||||
| FaxNumber: | 7049823850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7049861522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | N | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities | 320900000X | N | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 311Z00000X | N | Nursing & Custodial Care Facilities | Custodial Care Facility | 251S00000X | N | Agencies | Community/Behavioral Health | 315P00000X | MHL-084-011 | NC | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 3406415 | 05 | NC | MEDICAID |