Provider Demographics
NPI:1851447221
Name:LUTHERAN FAMILY SERVICES IN THE CAROLINAS
Entity Type:Organization
Organization Name:LUTHERAN FAMILY SERVICES IN THE CAROLINAS
Other - Org Name:MOUNTAIN RIDGE GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRBY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-754-8228
Mailing Address - Street 1:PO BOX 2369
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28145-2369
Mailing Address - Country:US
Mailing Address - Phone:704-637-2870
Mailing Address - Fax:
Practice Address - Street 1:810 KING ARTHUR DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-8469
Practice Address - Country:US
Practice Address - Phone:704-824-8941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN FAMILY SERVICES IN THE CAROLINAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCMHL036031315P00000X
NCMHL-036-031320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3416485Medicaid