Healthcare Provider Details

I. General information

NPI: 1477472405
Provider Name (Legal Business Name): HOMESTYLE LIVING HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13504 CIRCLE DR
CHARLOTTE NC
28262-2714
US

IV. Provider business mailing address

13504 CIRCLE DR
CHARLOTTE NC
28262-2714
US

V. Phone/Fax

Practice location:
  • Phone: 704-208-6518
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: NICOLE DEAN
Title or Position: CEO
Credential:
Phone: 704-208-6518