Provider Demographics
NPI:1639336878
Name:GOLDENBLUSH CIRCLE GROUP HOME
Entity Type:Organization
Organization Name:GOLDENBLUSH CIRCLE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAHOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-906-8893
Mailing Address - Street 1:6512 GOLDENBLUSH CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5102
Mailing Address - Country:US
Mailing Address - Phone:704-948-9701
Mailing Address - Fax:
Practice Address - Street 1:416 MCCULLOUGH DR
Practice Address - Street 2:SUITE 125
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4385
Practice Address - Country:US
Practice Address - Phone:704-547-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW LITE LIVING CHOICES,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603994Medicaid