Healthcare Provider Details

I. General information

NPI: 1891219093
Provider Name (Legal Business Name): TARHEEL RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2017
Last Update Date: 07/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 QUARRYMAN ROAD
RALEIGH NC
27610
US

IV. Provider business mailing address

4840 QUARRYMAN ROAD
RALEIGH NC
27610
US

V. Phone/Fax

Practice location:
  • Phone: 17042449069
  • Fax:
Mailing address:
  • Phone: 17042449069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. CONNIE YVETTE OMARI
Title or Position: CLINICAL DIRECTOR
Credential: LPC
Phone: 704-244-9069