1265799639 NPI number — ENSURE HOME CARE OF SOUTH CAROLINA

Table of content: (NPI 1265799639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265799639 NPI number — ENSURE HOME CARE OF SOUTH CAROLINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENSURE HOME CARE OF SOUTH CAROLINA
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:
1265799639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3437 PONDRIDGE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28269-2111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-975-2484
Provider Business Mailing Address Fax Number:
864-651-1142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1565 EBENEZER RD
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732-2494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-230-3415
Provider Business Practice Location Address Fax Number:
803-701-9131
Provider Enumeration Date:
04/23/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SIMMONS
Authorized Official First Name:
VELDA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANGER
Authorized Official Telephone Number:
704-258-6366

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: HC4546 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 372600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: EX1762 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".