Healthcare Provider Details

I. General information

NPI: 1033031034
Provider Name (Legal Business Name): TRUE TRACE RESIDENTIAL HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 BRIDGEFIELD PL APT 107
CHARLOTTE NC
28216-6030
US

IV. Provider business mailing address

1135 BRIDGEFIELD PL APT 107
CHARLOTTE NC
28216-6030
US

V. Phone/Fax

Practice location:
  • Phone: 704-915-8786
  • Fax:
Mailing address:
  • Phone: 704-915-8786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: QUANOLIA EUREKA SANDERS
Title or Position: OWNER
Credential:
Phone: 704-915-8786