=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902440118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINAS ALLIANCE FOR RESIDENTIAL EXCELLENCE HOLDINGS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2019
-----------------------------------------------------
Last Update Date | 10/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 JOHNSON RIDGE RD
-----------------------------------------------------
City | ELKIN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28621-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-677-1188
-----------------------------------------------------
Fax | 855-677-1189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 PINEOLA ST STE 300
-----------------------------------------------------
City | NEWLAND
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28657-7603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-677-1188
-----------------------------------------------------
Fax | 855-677-1189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | LAUREN ASHLEY REAVIS WARE
-----------------------------------------------------
Credential | RN, MSN, MBA
-----------------------------------------------------
Telephone | 336-408-5008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------