Provider Demographics
NPI:1225234743
Name:THE CYPRESS OF CHARLOTTE CLUB, INC.
Entity Type:Organization
Organization Name:THE CYPRESS OF CHARLOTTE CLUB, INC.
Other - Org Name:THE CYPRESS OF CHARLOTTE HOME CARE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-714-5500
Mailing Address - Street 1:3442 CYPRESS CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-2467
Mailing Address - Country:US
Mailing Address - Phone:704-714-5500
Mailing Address - Fax:704-714-5501
Practice Address - Street 1:3442 CYPRESS CLUB DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-2467
Practice Address - Country:US
Practice Address - Phone:704-714-5500
Practice Address - Fax:704-714-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1907251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC1907OtherSTATE LICENSE