Provider Demographics
NPI:1851739643
Name:FALCON CREST RESIDENTIAL
Entity Type:Organization
Organization Name:FALCON CREST RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISRTATOR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BRADSHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-226-2575
Mailing Address - Street 1:1101 S FIFTH ST
Mailing Address - Street 2:PO BOX 1670
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-9182
Mailing Address - Country:US
Mailing Address - Phone:336-226-2575
Mailing Address - Fax:336-226-2474
Practice Address - Street 1:3309A N NC HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217
Practice Address - Country:US
Practice Address - Phone:336-226-2575
Practice Address - Fax:336-226-2474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-001-103251S00000X, 320800000X
NC6603415320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603415Medicaid