Provider Demographics
NPI:1396924221
Name:CLASSIQUE RESIDENTIAL SERVICES-LLC
Entity type:Organization
Organization Name:CLASSIQUE RESIDENTIAL SERVICES-LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:AUGUSTUS
Authorized Official - Last Name:LUTTERODT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:336-510-6966
Mailing Address - Street 1:340 BURLINGATE DR APT E
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1295
Mailing Address - Country:US
Mailing Address - Phone:336-510-6966
Mailing Address - Fax:
Practice Address - Street 1:340 BURLINGATE DR APT E
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1295
Practice Address - Country:US
Practice Address - Phone:336-510-6966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-27
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320600000X
NC320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities