Provider Demographics
NPI:1497751598
Name:HERTFORD COUNTY PUBLIC HEALTH AUTHORITY
Entity Type:Organization
Organization Name:HERTFORD COUNTY PUBLIC HEALTH AUTHORITY
Other - Org Name:HERTFORD-GATES HOME HEALTH AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM HEALTH DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLAWHORN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-862-4054
Mailing Address - Street 1:704 EVANS ST
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-9592
Mailing Address - Country:US
Mailing Address - Phone:252-332-6747
Mailing Address - Fax:252-332-5089
Practice Address - Street 1:704 EVANS ST
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-9592
Practice Address - Country:US
Practice Address - Phone:252-332-6747
Practice Address - Fax:252-332-5089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC0504251E00000X
NCHC1062251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00741OtherBLUE CROSS/BLUE SHIELD
NC341-7049Medicaid
NC00741OtherBLUE CROSS/BLUE SHIELD