Healthcare Provider Details

I. General information

NPI: 1649387200
Provider Name (Legal Business Name): FOOTPRINTS CAROLINA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 REMOUNT RD
GASTONIA NC
28054-7437
US

IV. Provider business mailing address

5700 EXECUTIVE CENTER DR STE 100
CHARLOTTE NC
28212-8833
US

V. Phone/Fax

Practice location:
  • Phone: 704-524-2009
  • Fax: 704-524-2095
Mailing address:
  • Phone: 704-566-3460
  • Fax: 704-566-3461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RICHARD ANDERSON SR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 704-884-2500