Healthcare Provider Details

I. General information

NPI: 1881521813
Provider Name (Legal Business Name): CAROLINA COMMUNITY GROUP TRIAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2818 QUEEN CITY DR STE N
CHARLOTTE NC
28208-2736
US

IV. Provider business mailing address

2818 QUEEN CITY DR STE N
CHARLOTTE NC
28208-2736
US

V. Phone/Fax

Practice location:
  • Phone: 704-912-4505
  • Fax:
Mailing address:
  • Phone: 704-912-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State

VIII. Authorized Official

Name: IVORY D BETHEA
Title or Position: DIRECTOR
Credential:
Phone: 704-582-1793