Provider Demographics
NPI:1518032267
Name:COMMUNITY LIVING CONCEPTS OF NC, INC.
Entity Type:Organization
Organization Name:COMMUNITY LIVING CONCEPTS OF NC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-788-2080
Mailing Address - Street 1:440 ACTION DRIVE NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027
Mailing Address - Country:US
Mailing Address - Phone:704-788-2080
Mailing Address - Fax:704-788-2088
Practice Address - Street 1:211 SOUTH CENTER ST.
Practice Address - Street 2:SUITE 403
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5873
Practice Address - Country:US
Practice Address - Phone:704-838-0016
Practice Address - Fax:704-838-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 320900000X
NC320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301157Medicaid
NC8301158Medicaid
NC8301477Medicaid
NC3409659Medicaid