Provider Demographics
NPI:1558425884
Name:GASTON RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:GASTON RESIDENTIAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-861-9280
Mailing Address - Street 1:905A N NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3354
Mailing Address - Country:US
Mailing Address - Phone:704-861-9280
Mailing Address - Fax:704-868-2154
Practice Address - Street 1:905A N NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3354
Practice Address - Country:US
Practice Address - Phone:704-861-9280
Practice Address - Fax:704-868-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-036-239OtherFAIRVIEW GROUP HOME LICENSE
NC8300506Medicaid
NC7802582Medicaid
NC7804622Medicaid
NC3408863Medicaid
NC7802105Medicaid
NC7802058Medicaid
NC7802058Medicaid