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General NPI Number Information
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NPI Number | 1508360892
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Entity Type | Organization
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Legal Business Name | CONCRETE ROSES LIFE CENTER
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Dates
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Enumeration Date | 03/21/2018
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Last Update Date | 09/02/2021
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Provider Practice Location Address
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Address Line | 5960 FAIRVIEW RD STE 323
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City | CHARLOTTE
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State | NC
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Zip | 28210-3102
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Country | US
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Telephone | 980-263-0991
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Fax |
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Provider Business Mailing Address
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Address Line | 2040 RANDOLPH RD STE A
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City | CHARLOTTE
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State | NC
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Zip | 28207-1239
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Country | US
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Telephone | 980-219-8622
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SHAUKURA MANDISA BROWN
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Credential |
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Telephone | 980-263-0991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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Taxonomy #4
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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Taxonomy #6
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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Taxonomy #7
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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Taxonomy #9
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 261QP0904X
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Taxonomy Name | Federal Public Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 261QP0905X
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Taxonomy Name | State or Local Public Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #14
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Taxonomy Code | 385HR2050X
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Taxonomy Name | Respite Care Camp
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License Number |
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License Number State |
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Taxonomy #15
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number |
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License Number State |
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