Provider Demographics
NPI:1427180975
Name:CAROLINA RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:CAROLINA RESIDENTIAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KINCAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-572-2333
Mailing Address - Street 1:PO BOX 286
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD COLLEGE
Mailing Address - State:NC
Mailing Address - Zip Code:28671-0286
Mailing Address - Country:US
Mailing Address - Phone:828-572-2333
Mailing Address - Fax:980-225-0500
Practice Address - Street 1:130 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27011-9300
Practice Address - Country:US
Practice Address - Phone:336-367-9039
Practice Address - Fax:336-367-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-11
Last Update Date:2013-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 311ZA0620X
NCMHL 099015320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7806585Medicaid
NC7805080Medicaid