Healthcare Provider Details

I. General information

NPI: 1649849241
Provider Name (Legal Business Name): CITY SOURCE REALTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 SARDIS RD N STE 216
CHARLOTTE NC
28270-3000
US

IV. Provider business mailing address

1419 REIDHAVEN ST
MATTHEWS NC
28105-7727
US

V. Phone/Fax

Practice location:
  • Phone: 704-981-0505
  • Fax:
Mailing address:
  • Phone: 980-833-9227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: SHAYNA E TONIA
Title or Position: OWNER
Credential:
Phone: 704-981-0505