Healthcare Provider Details

I. General information

NPI: 1376725366
Provider Name (Legal Business Name): FOOTPRINTS CAROLINA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 FIRST STREET
SHELBY NC
28150-3958
US

IV. Provider business mailing address

2020 REMOUNT RD
GASTONIA NC
28054-7476
US

V. Phone/Fax

Practice location:
  • Phone: 704-480-6641
  • Fax: 704-480-1364
Mailing address:
  • Phone: 704-884-2500
  • Fax: 704-524-2095

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: MR. RICHARD ANDERSON
Title or Position: CEO
Credential: BS
Phone: 704-884-2500