Provider Demographics
NPI:1770727281
Name:COZIE'S SUPERVISED LIVING INC
Entity type:Organization
Organization Name:COZIE'S SUPERVISED LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:DEMETRUS
Authorized Official - Last Name:SHOFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-549-1081
Mailing Address - Street 1:7964 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:27298-9655
Mailing Address - Country:US
Mailing Address - Phone:336-622-2754
Mailing Address - Fax:336-622-1420
Practice Address - Street 1:7964 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298-9590
Practice Address - Country:US
Practice Address - Phone:336-622-2754
Practice Address - Fax:336-622-1420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-076-098323P00000X
NCMHL-001-074323P00000X, 385H00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409308Medicaid
NC7803981Medicaid