Provider Demographics
NPI:1174669261
Name:PIEDMONT RESIDENTIAL DEVELOPMENT CENTER, INC
Entity Type:Organization
Organization Name:PIEDMONT RESIDENTIAL DEVELOPMENT CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIPKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-788-2304
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28026-0909
Mailing Address - Country:US
Mailing Address - Phone:704-788-2304
Mailing Address - Fax:704-788-2951
Practice Address - Street 1:630 WILHELM PL NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2532
Practice Address - Country:US
Practice Address - Phone:704-788-2304
Practice Address - Fax:704-788-2951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-013-019315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406118Medicaid