Provider Demographics
NPI:1104944081
Name:FALCON CREST RESIDENTIAL CARE
Entity type:Organization
Organization Name:FALCON CREST RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM. MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BRADSHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-226-2575
Mailing Address - Street 1:1101 SOUTH FIFTH STREET
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-1101
Mailing Address - Country:US
Mailing Address - Phone:336-226-2575
Mailing Address - Fax:336-226-2474
Practice Address - Street 1:1101 S FIFTH ST
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-9182
Practice Address - Country:US
Practice Address - Phone:336-226-2575
Practice Address - Fax:336-226-2474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC753096607320600000X
NCMHL-001-141320600000X, 322D00000X
NCMHL-001-103322D00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603770Medicaid
NC6603998Medicaid
NC6603415Medicaid