1104940782 NPI number — PASSIONATE CARE GROUP HOME

Table of content: (NPI 1104940782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104940782 NPI number — PASSIONATE CARE GROUP HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PASSIONATE CARE GROUP HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104940782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
727 HONEYSPOT RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06615-7172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-378-0433
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 WALNUT CREEK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27520-7242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-332-2171
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ALTMAN
Authorized Official First Name:
CHANTA'E
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS/CFO
Authorized Official Telephone Number:
919-332-2171

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  MHL 051144 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7805103 . This is a "PROVIDER NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".