Provider Demographics
NPI:1518613330
Name:MGA HOME HEALTHCARE FAYETTEVILLE, LLC
Entity Type:Organization
Organization Name:MGA HOME HEALTHCARE FAYETTEVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, RN
Authorized Official - Phone:910-839-0239
Mailing Address - Street 1:3400 WALSH PKWY STE 248
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1642
Mailing Address - Country:US
Mailing Address - Phone:910-839-0239
Mailing Address - Fax:910-900-0915
Practice Address - Street 1:3400 WALSH PKWY STE 248
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1642
Practice Address - Country:US
Practice Address - Phone:910-839-0239
Practice Address - Fax:910-900-0915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC6297Medicaid