Provider Demographics
NPI:1265667075
Name:GASTON RESIDENTIAL SERVICES, ICF/MR, INC.
Entity Type:Organization
Organization Name:GASTON RESIDENTIAL SERVICES, ICF/MR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEMPERIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-861-9280
Mailing Address - Street 1:905 N NEW HOPE RD STE A
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3373
Mailing Address - Country:US
Mailing Address - Phone:704-861-9280
Mailing Address - Fax:704-868-2154
Practice Address - Street 1:138 MEEK RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-9075
Practice Address - Country:US
Practice Address - Phone:704-861-9280
Practice Address - Fax:704-868-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406472Medicaid