Provider Demographics
NPI:1356652390
Name:FOOTPRINTS CAROLINA, LLC
Entity Type:Organization
Organization Name:FOOTPRINTS CAROLINA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-884-2554
Mailing Address - Street 1:2020 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7476
Mailing Address - Country:US
Mailing Address - Phone:704-884-2500
Mailing Address - Fax:704-524-2095
Practice Address - Street 1:918 WEST AVE NW
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5191
Practice Address - Country:US
Practice Address - Phone:828-572-2424
Practice Address - Fax:828-572-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management