Provider Demographics
| NPI: | 1508360892 |
|---|---|
| Name: | CONCRETE ROSES LIFE CENTER |
| Entity Type: | Organization |
| Organization Name: | CONCRETE ROSES LIFE CENTER |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | SHAUKURA |
| Authorized Official - Middle Name: | MANDISA |
| Authorized Official - Last Name: | BROWN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 980-263-0991 |
| Mailing Address - Street 1: | 2040 RANDOLPH RD STE A |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CHARLOTTE |
| Mailing Address - State: | NC |
| Mailing Address - Zip Code: | 28207-1239 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 980-219-8622 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 5960 FAIRVIEW RD STE 323 |
| Practice Address - Street 2: | |
| Practice Address - City: | CHARLOTTE |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 28210-3102 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 980-263-0991 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2018-03-21 |
| Last Update Date: | 2021-09-02 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
| No | 251B00000X | Agencies | Case Management | |
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | |
| No | 251S00000X | Agencies | Community/Behavioral Health | |
| No | 251V00000X | Agencies | Voluntary or Charitable | |
| No | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
| No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
| No | 261QP0904X | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal |
| No | 261QP0905X | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local |
| No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
| No | 3245S0500X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
| No | 385HR2050X | Respite Care Facility | Respite Care | Respite Care Camp |
| No | 385HR2060X | Respite Care Facility | Respite Care | Respite Care, Intellectual and/or Developmental Disabilities, Child |
