Basic Information
| Provider Information | |||||||||
| NPI: | 1770705956 | ||||||||
| 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: | 314 EAST WESTBROOK STREET | ||||||||
| Address2: | |||||||||
| City: | WALLACE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284661533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102855319 | ||||||||
| FaxNumber: | 9102855438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | KINCAID | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8285722333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | MHL 031063 | NC | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 7805778 | 05 | NC | MEDICAID | 7806594 | 05 | NC | MEDICAID |