Provider Demographics
NPI:1750161568
Name:K&R GLOWING PRIDE RESIDENTIAL SERVICES OF NORTH CAROLINA
Entity type:Organization
Organization Name:K&R GLOWING PRIDE RESIDENTIAL SERVICES OF NORTH CAROLINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KEYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-517-7688
Mailing Address - Street 1:2819 MATERA DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-9155
Mailing Address - Country:US
Mailing Address - Phone:317-517-7688
Mailing Address - Fax:
Practice Address - Street 1:11512 SPRING LAUREL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-4654
Practice Address - Country:US
Practice Address - Phone:317-517-7688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health