Provider Demographics
NPI:1093447666
Name:CAROLINA COMMUNITY GROUP
Entity type:Organization
Organization Name:CAROLINA COMMUNITY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IVORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BETHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-502-5879
Mailing Address - Street 1:4037 E INDEPENDENCE BLVD
Mailing Address - Street 2:416
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205
Mailing Address - Country:US
Mailing Address - Phone:704-582-1793
Mailing Address - Fax:
Practice Address - Street 1:4037 E INDEPENDENCE BLVD
Practice Address - Street 2:416
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205
Practice Address - Country:US
Practice Address - Phone:704-582-1793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLISSFUL MINDS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-30
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health