Provider Demographics
NPI:1417196353
Name:WILSON'S HOME CARE AGENCY
Entity Type:Organization
Organization Name:WILSON'S HOME CARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WIL;SON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-244-3595
Mailing Address - Street 1:7914 MAIN ST.
Mailing Address - Street 2:PO BOX 1022
Mailing Address - City:VANCEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28586-1022
Mailing Address - Country:US
Mailing Address - Phone:252-244-3595
Mailing Address - Fax:252-244-3163
Practice Address - Street 1:1528 SO EVAN ST.
Practice Address - Street 2:SIUTE M
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5311
Practice Address - Country:US
Practice Address - Phone:252-353-8020
Practice Address - Fax:252-353-8040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC21703747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6600834Medicaid