Provider Demographics
NPI:1124600143
Name:ETHEREAL CARE LLC
Entity Type:Organization
Organization Name:ETHEREAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-303-2778
Mailing Address - Street 1:3902 WOODBERRY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-0944
Mailing Address - Country:US
Mailing Address - Phone:336-303-2778
Mailing Address - Fax:
Practice Address - Street 1:2216 W MEADOWVIEW RD STE 264
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3406
Practice Address - Country:US
Practice Address - Phone:336-303-2778
Practice Address - Fax:855-827-7407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No385H00000XRespite Care FacilityRespite Care