Provider Demographics
NPI:1528197787
Name:ST. MARY'S HOME CARE
Entity Type:Organization
Organization Name:ST. MARY'S HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELTON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:919-363-1462
Mailing Address - Street 1:243 DABNEY DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-4033
Mailing Address - Country:US
Mailing Address - Phone:252-430-6873
Mailing Address - Fax:252-430-6927
Practice Address - Street 1:243 DABNEY DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4033
Practice Address - Country:US
Practice Address - Phone:252-430-6873
Practice Address - Fax:252-430-6927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2392251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601244Medicaid