1740424639 NPI number — HOMESTEAD PLACE

Table of content: (NPI 1740424639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740424639 NPI number — HOMESTEAD PLACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOMESTEAD PLACE
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:
1740424639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3107 S ELM EUGENE ST
Provider Second Line Business Mailing Address:
BUILDING A
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27406-5201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-273-2640
Provider Business Mailing Address Fax Number:
336-273-6522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2032 HOMESTEAD PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27516-9076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-240-5016
Provider Business Practice Location Address Fax Number:
336-273-6522
Provider Enumeration Date:
04/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
336-273-2640

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X , with the licence number:  MHL-068-139 , 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: 7806104 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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