=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740430388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROWN RESIDENTIAL SUPPORT SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2008
-----------------------------------------------------
Last Update Date | 09/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5523 WINDY VALLEY DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28208-1191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-391-5588
-----------------------------------------------------
Fax | 704-391-5588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5523 WINDY VALLEY DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28208-1191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-391-5588
-----------------------------------------------------
Fax | 704-391-5588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. ANTHONY C BROWN
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 704-391-5588
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------