Provider Demographics
NPI:1891859203
Name:GASTON RESIDENTIAL SERVICES, ICF/MR, INC.
Entity Type:Organization
Organization Name:GASTON RESIDENTIAL SERVICES, ICF/MR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAIMEE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEIDERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-861-9280
Mailing Address - Street 1:905A N NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3354
Mailing Address - Country:US
Mailing Address - Phone:704-861-9280
Mailing Address - Fax:704-868-2154
Practice Address - Street 1:1101 E FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4251
Practice Address - Country:US
Practice Address - Phone:704-861-9280
Practice Address - Fax:704-868-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-036-022315P00000X
NCMHL-036-069315P00000X
NCMHL-036-016315P00000X
NCMHL-036-011315P00000X
NCMHL-036-046315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406373Medicaid
NC3406290Medicaid
NC3406472Medicaid
NC3406432Medicaid
NC3406554Medicaid