Healthcare Provider Details

I. General information

NPI: 1427180975
Provider Name (Legal Business Name): CAROLINA RESIDENTIAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2007
Last Update Date: 07/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 WILLIAMS ST
BOONVILLE NC
27011-9300
US

IV. Provider business mailing address

PO BOX 286
RUTHERFORD COLLEGE NC
28671-0286
US

V. Phone/Fax

Practice location:
  • Phone: 336-367-9039
  • Fax: 336-367-9039
Mailing address:
  • Phone: 828-572-2333
  • Fax: 980-225-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL 099015
License Number StateNC

VIII. Authorized Official

Name: MS. SUSAN M KINCAID
Title or Position: DIRECTOR
Credential:
Phone: 828-572-2333