Organization
EDUCARE COMMUNITY LIVING CORP NORTH CAROLINA
Active
Other names
Konnoak Drive Group Home
Organization subpart
No
Provider details
NPI number
Authorized official
ANGIE MATTINGLY (MGR PROVIDER ENROLLMENT)
(502) 630-7425
Entity
Organization
Contact information
Practice address
2901 KONNOAK DR, WINSTON SALEM, NC 27127-3945
(800) 866-0860
Mailing address
805 N WHITTINGTON PKWY, LOUISVILLE, KY 40222-7101
(800) 866-0860
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
—
NC
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
342606W
—
NC
Enumeration date
04/30/2009
Last updated
02/21/2022
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