Healthcare Provider Details

I. General information

NPI: 1063544518
Provider Name (Legal Business Name): CAROLINA RESIDENTIAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2007
Last Update Date: 07/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 ELK SPUR ST
ELKIN NC
28621-3206
US

IV. Provider business mailing address

PO BOX 286
RUTHERFORD COLLEGE NC
28671-0286
US

V. Phone/Fax

Practice location:
  • Phone: 336-835-1101
  • Fax: 336-835-1101
Mailing address:
  • Phone: 828-572-2333
  • Fax: 980-225-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL 086038
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. SUSAN M KINCAID
Title or Position: DIRECTOR
Credential:
Phone: 828-572-2333