Provider Demographics
NPI:1215545348
Name:CAROLINA PRIME RESIDENTIAL LLC
Entity Type:Organization
Organization Name:CAROLINA PRIME RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIKISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-717-2040
Mailing Address - Street 1:315 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5513
Mailing Address - Country:US
Mailing Address - Phone:336-763-5620
Mailing Address - Fax:
Practice Address - Street 1:315 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5513
Practice Address - Country:US
Practice Address - Phone:336-623-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-15
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness