MEDICARE: RESIDENTIAL OPTION SERVING ADOLESCENTS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
2	3245S0500X	Children's Substance Abuse Rehabilitation Facility
3	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1578160552
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESIDENTIAL OPTION SERVING ADOLESCENTS, LLC

Provider Business Mailing Address
First Line	:	2316 CARVED TREE LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-3154
Country	:	US
Telephone Number	:	704-622-4918
Fax Number	:

Provider Business Practice Location Address
First Line	:	2316 CARVED TREE LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-3154
Country	:	US
Telephone Number	:	704-622-4918
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LORI ANN WASHINGTON
Credential	:
Telephone Number	:	704-622-4918

Provider Enumeration Date	:	10/03/2020
Last Update Date	:	10/03/2020

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