Healthcare Provider Details

I. General information

NPI: 1700902897
Provider Name (Legal Business Name): GENTLEMEN'S QUARTERS I., LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S MAIN ST APT. 91
MOUNT HOLLY NC
28120-2048
US

IV. Provider business mailing address

105 STONERIDGE DR
MOUNT HOLLY NC
28120-2041
US

V. Phone/Fax

Practice location:
  • Phone: 704-820-9449
  • Fax: 704-827-0718
Mailing address:
  • Phone: 704-853-2665
  • Fax: 704-853-2665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHL-036-251
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-036-251
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY KATEAR ANDERSON
Title or Position: EXECUTIVE DIRECTOR
Credential: B.S
Phone: 704-853-2665