Provider Demographics
NPI:1467443945
Name:THE CYPRESS OF CHARLOTTE CLUB INC.
Entity Type:Organization
Organization Name:THE CYPRESS OF CHARLOTTE CLUB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-714-5500
Mailing Address - Street 1:3442 CYPRESS CLUB DRIVE
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 1:6920 MARCHING DUCK DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3288
Practice Address - Country:US
Practice Address - Phone:704-714-5555
Practice Address - Fax:704-714-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0584314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC345495Medicare Oscar/Certification