Provider Demographics
NPI:1275689242
Name:GRANVILLE-VANCE DISTRICT HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:GRANVILLE-VANCE DISTRICT HEALTH DEPARTMENT
Other - Org Name:GRANVILLE-VANCE HOME HEALTH AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILTON
Authorized Official - Middle Name:RODWELL
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:9619-693-2141
Mailing Address - Street 1:101 HUNT ST
Mailing Address - Street 2:PO BOX 367
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-3414
Mailing Address - Country:US
Mailing Address - Phone:919-693-2141
Mailing Address - Fax:919-693-8517
Practice Address - Street 1:125 CHARLES ROLLINS ROAD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-0000
Practice Address - Country:US
Practice Address - Phone:252-492-5831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
34D1034140OtherCLIA #
NCHC0501OtherLICENSE #
NC3407062Medicaid
34D1034140OtherCLIA #
NC3407062Medicaid