Provider Demographics
NPI:1114088416
Name:STAT ETC, INC.
Entity Type:Organization
Organization Name:STAT ETC, INC.
Other - Org Name:QUEEN CITY HOME CARE & MEDICAL STAFFING
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOLETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-217-5231
Mailing Address - Street 1:PO BOX 29562
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28229-9562
Mailing Address - Country:US
Mailing Address - Phone:980-217-5231
Mailing Address - Fax:919-400-4201
Practice Address - Street 1:4917 ALBEMARLE RD STE 206
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6686
Practice Address - Country:US
Practice Address - Phone:980-217-5231
Practice Address - Fax:919-400-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3156251E00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7100577Medicaid
NC3418002Medicaid
NC6601380Medicaid
NC6800485Medicaid