Provider Demographics
NPI:1982338778
Name:EXTENDED FAMILY RESIDENCES, LLC
Entity Type:Organization
Organization Name:EXTENDED FAMILY RESIDENCES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LATOYIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-804-6049
Mailing Address - Street 1:7330 CLAIBORNE WOODS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-5779
Mailing Address - Country:US
Mailing Address - Phone:980-209-9987
Mailing Address - Fax:
Practice Address - Street 1:7330 CLAIBORNE WOODS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-5779
Practice Address - Country:US
Practice Address - Phone:614-804-6049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-15
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities