Provider Demographics
NPI:1467505305
Name:PROFESSIONAL CARE HOME HEALTH SERVI
Entity Type:Organization
Organization Name:PROFESSIONAL CARE HOME HEALTH SERVI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
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
Mailing Address - Country:US
Mailing Address - Phone:336-725-0755
Mailing Address - Fax:
Practice Address - Street 1:2070 CLOVERDALE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-725-0755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8700436Medicaid