Organization
CAROLINA PRIME RESIDENTIAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MIKISHA SIMMS (DIRECTOR)
(301) 717-2040
Entity
Organization
Contact information
Practice address
315 MAPLE ST, EDEN, NC 27288-5513
(336) 623-1020
Mailing address
315 MAPLE ST, EDEN, NC 27288-5513
(336) 763-5620
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Enumeration date
07/15/2020
Last updated
04/10/2024
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