Healthcare Provider Details

I. General information

NPI: 1730880873
Provider Name (Legal Business Name): EMERALD HEART FAMILY CARE HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 REEDMONT LN
CHARLOTTE NC
28269-1631
US

IV. Provider business mailing address

4911 REEDMONT LN
CHARLOTTE NC
28269-1631
US

V. Phone/Fax

Practice location:
  • Phone: 704-309-9244
  • 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
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHARNEICE KHALEA DAVIS
Title or Position: OWNER
Credential: RN
Phone: 704-309-9244