Provider Demographics
NPI:1275604134
Name:CLASSIC CARE HOME CARE
Entity Type:Organization
Organization Name:CLASSIC CARE HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MERVA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:910-235-9009
Mailing Address - Street 1:PO BOX 651
Mailing Address - Street 2:108 ARROWLEAF LANE
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376-0651
Mailing Address - Country:US
Mailing Address - Phone:910-235-9009
Mailing Address - Fax:910-235-9008
Practice Address - Street 1:108 ARROWLEAF LN
Practice Address - Street 2:
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376-9795
Practice Address - Country:US
Practice Address - Phone:910-235-9009
Practice Address - Fax:910-235-9008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLASSIC CARE HOME CARE AGENCY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3217251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601419Medicaid