Provider Demographics
NPI:1457482317
Name:PERSONAL HOME CARE OF NORTH CAROLINA, LLC
Entity Type:Organization
Organization Name:PERSONAL HOME CARE OF NORTH CAROLINA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BELOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-522-6144
Mailing Address - Street 1:1515 MOCKINGBIRD LN STE 520
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3297
Mailing Address - Country:US
Mailing Address - Phone:704-522-6144
Mailing Address - Fax:704-522-6145
Practice Address - Street 1:1515 MOCKINGBIRD LN STE 520
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:704-522-6144
Practice Address - Fax:704-522-6145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409657Medicaid