1124437371 NPI number — RELIANCE HEALTH SOURCE LLC

Table of content: (NPI 1124437371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124437371 NPI number — RELIANCE HEALTH SOURCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RELIANCE HEALTH SOURCE LLC
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:
IN HOME QUALITY CARE
Provider Other Organization Name Type Code:
3
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:
1124437371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 S WESTGATE DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27407-1640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-844-4684
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 S WESTGATE DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27407-1640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-844-4684
Provider Business Practice Location Address Fax Number:
336-740-9342
Provider Enumeration Date:
08/12/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARNETTE
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
ASAD
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
336-844-4684

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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