Provider Demographics
NPI:1053588038
Name:FOOTPRINTS CAROLINA INC
Entity type:Organization
Organization Name:FOOTPRINTS CAROLINA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-524-2091
Mailing Address - Street 1:2020 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7476
Mailing Address - Country:US
Mailing Address - Phone:704-884-2500
Mailing Address - Fax:704-524-2097
Practice Address - Street 1:138 ALLENDALE DR
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-2874
Practice Address - Country:US
Practice Address - Phone:828-248-9990
Practice Address - Fax:828-248-9770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC36265Medicaid