1083151195 NPI number — SWEET WATERS HOMECARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083151195 NPI number — SWEET WATERS HOMECARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SWEET WATERS HOMECARE, 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:
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:
1083151195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2075 N MARINE BLVD
Provider Second Line Business Mailing Address:
SUITE U, #337
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28546-5535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-319-9387
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 STONEMARK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28540-9170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-330-1082
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
MOSES
Authorized Official Middle Name:
LEONARD
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
910-330-1082

Provider Taxonomy Codes

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

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





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