Provider Demographics
NPI:1104943448
Name:RESIDENTIAL & SUPPORT SERVICES, INC.
Entity type:Organization
Organization Name:RESIDENTIAL & SUPPORT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUGEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-536-6661
Mailing Address - Street 1:4425 RANDOLPH RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2351
Mailing Address - Country:US
Mailing Address - Phone:704-536-6661
Mailing Address - Fax:704-536-0074
Practice Address - Street 1:4425 RANDOLPH RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2351
Practice Address - Country:US
Practice Address - Phone:704-536-6661
Practice Address - Fax:704-536-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301185BMedicaid