Provider Demographics
NPI:1235396466
Name:PROFESSIONAL CARE HOME HEALTH SERVICES
Entity Type:Organization
Organization Name:PROFESSIONAL CARE HOME HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:Y'LONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-725-0755
Mailing Address - Street 1:2070 CLOVERDALE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2503
Mailing Address - Country:US
Mailing Address - Phone:336-725-0755
Mailing Address - Fax:336-725-0756
Practice Address - Street 1:3721 EASTWAY DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6266
Practice Address - Country:US
Practice Address - Phone:704-536-7326
Practice Address - Fax:704-536-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00000251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8700474Medicaid