Provider Demographics
NPI:1891262010
Name:FALCON CREST RESIDENTIAL CARE
Entity Type:Organization
Organization Name:FALCON CREST RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:KAY
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:
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:
Practice Address - Street 1:1433 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-1718
Practice Address - Country:US
Practice Address - Phone:336-226-2575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FALCON CREST RESIDENTIAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid