Provider Demographics
NPI:1003373952
Name:SENIOR HOME SHARE, LLC
Entity Type:Organization
Organization Name:SENIOR HOME SHARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-238-1448
Mailing Address - Street 1:1002 E STUART DR STE 3
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2664
Mailing Address - Country:US
Mailing Address - Phone:276-238-1448
Mailing Address - Fax:276-601-2587
Practice Address - Street 1:1002 E STUART DR STE 3
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2664
Practice Address - Country:US
Practice Address - Phone:276-238-1448
Practice Address - Fax:276-601-2587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE24637778OtherDRIVER'S LICENSE