Healthcare Provider Details

I. General information

NPI: 1982338778
Provider Name (Legal Business Name): EXTENDED FAMILY RESIDENCES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 CLAIBORNE WOODS RD
CHARLOTTE NC
28216-5779
US

IV. Provider business mailing address

7330 CLAIBORNE WOODS RD
CHARLOTTE NC
28216-5779
US

V. Phone/Fax

Practice location:
  • Phone: 614-804-6049
  • Fax:
Mailing address:
  • Phone: 980-209-9987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: LATOYIA ROBERTS
Title or Position: CEO
Credential:
Phone: 614-804-6049