Provider Demographics
NPI:1649387200
Name:FOOTPRINTS CAROLINA, INC
Entity Type:Organization
Organization Name:FOOTPRINTS CAROLINA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:704-884-2500
Mailing Address - Street 1:5700 EXECUTIVE CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8833
Mailing Address - Country:US
Mailing Address - Phone:704-566-3460
Mailing Address - Fax:704-566-3461
Practice Address - Street 1:2020 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7437
Practice Address - Country:US
Practice Address - Phone:704-524-2009
Practice Address - Fax:704-524-2095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005997Medicaid