Healthcare Provider Details

I. General information

NPI: 1598537151
Provider Name (Legal Business Name): FAITH RESIDENTIAL HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5823 HEWITT DR
CHARLOTTE NC
28269-0219
US

IV. Provider business mailing address

5414 JASLIE LN
CHARLOTTE NC
28227-2650
US

V. Phone/Fax

Practice location:
  • Phone: 704-617-9859
  • Fax:
Mailing address:
  • Phone: 704-617-9859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: HELLEN ALEM DESSALEGN
Title or Position: OWNER
Credential:
Phone: 704-617-9859