1811494107 NPI number — EXCELLENT SUPPORT CARE CORP.

Table of content: (NPI 1811494107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811494107 NPI number — EXCELLENT SUPPORT CARE CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCELLENT SUPPORT CARE CORP.
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:
1811494107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 VAN NORDEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27889-4346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
862-309-9533
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 VAN NORDEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27889-4346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
862-309-9533
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
REDDICK
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
917-995-3112

Provider Taxonomy Codes

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

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

  • Identifier: 1811494107 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com