Healthcare Provider Details

I. General information

NPI: 1407773401
Provider Name (Legal Business Name): PRIME GENERATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2642 FORBES RD
GASTONIA NC
28056-5206
US

IV. Provider business mailing address

10540 ENGLISH SETTER WAY
CHARLOTTE NC
28269-1356
US

V. Phone/Fax

Practice location:
  • Phone: 704-516-7190
  • Fax: 704-516-7190
Mailing address:
  • Phone: 704-516-7190
  • Fax: 704-516-7190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHEN WASHINGTON
Title or Position: PROGRAM DIRECTOR
Credential: WASHINGTON
Phone: 704-516-7190