Provider Demographics
NPI:1649849241
Name:CITY SOURCE REALTY
Entity type:Organization
Organization Name:CITY SOURCE REALTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAYNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:TONIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-981-0505
Mailing Address - Street 1:1419 REIDHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-7727
Mailing Address - Country:US
Mailing Address - Phone:980-833-9227
Mailing Address - Fax:
Practice Address - Street 1:1811 SARDIS RD N STE 216
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-3000
Practice Address - Country:US
Practice Address - Phone:704-981-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty