Provider Demographics
NPI:1326435314
Name:CROWN LEGACY SUPPORTIVE SERVICESLLC
Entity Type:Organization
Organization Name:CROWN LEGACY SUPPORTIVE SERVICESLLC
Other - Org Name:BRADLEY-REID CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:MHA,MBA
Authorized Official - Phone:704-333-5686
Mailing Address - Street 1:715 E 5TH ST
Mailing Address - Street 2:SUITE 216
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3001
Mailing Address - Country:US
Mailing Address - Phone:704-333-5686
Mailing Address - Fax:704-376-1931
Practice Address - Street 1:715 E 5TH ST
Practice Address - Street 2:SUITE 216
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-3001
Practice Address - Country:US
Practice Address - Phone:704-333-5686
Practice Address - Fax:704-376-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008557Medicaid