Provider Demographics
NPI:1528166055
Name:GIC OF CHARLOTTE, INC
Entity type:Organization
Organization Name:GIC OF CHARLOTTE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADIAHA
Authorized Official - Middle Name:ETTE
Authorized Official - Last Name:STRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:980-428-2660
Mailing Address - Street 1:2137 B AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-3705
Mailing Address - Country:US
Mailing Address - Phone:704-393-8206
Mailing Address - Fax:704-973-7944
Practice Address - Street 1:2137 B AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-3705
Practice Address - Country:US
Practice Address - Phone:704-393-8206
Practice Address - Fax:704-973-7944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-949251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409494Medicaid