Organization
GASTON RESIDENTIAL SERVICES, ICF/MR, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAIMEE D WEIDERT (FINANCE DIRECTOR)
(704) 861-9280
Entity
Organization
Contact information
Practice address
1101 E FRANKLIN BLVD, GASTONIA, NC 28054-4251
(704) 861-9280
(704) 868-2154
Mailing address
905A N NEW HOPE RD, GASTONIA, NC 28054-3354
(704) 861-9280
(704) 868-2154
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
MHL-036-011
NC
315P00000X
Intellectual Disabilities Intermediate Care Facility
MHL-036-016
NC
315P00000X
Intellectual Disabilities Intermediate Care Facility
MHL-036-022
NC
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
MHL-036-046
NC
315P00000X
Intellectual Disabilities Intermediate Care Facility
MHL-036-069
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3406290
—
NC
05
—
3406373
—
NC
05
—
3406432
—
NC
05
—
3406472
—
NC
05
—
3406554
—
NC
Enumeration date
12/20/2006
Last updated
04/08/2019
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