Provider Demographics
NPI:1558501221
Name:CONVENANT HOMECARE AGENCY
Entity Type:Organization
Organization Name:CONVENANT HOMECARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PRECIOUSE
Authorized Official - Middle Name:ADULA
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN,MBA/HCM
Authorized Official - Phone:704-576-6553
Mailing Address - Street 1:4221 CHATTERLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8102
Mailing Address - Country:US
Mailing Address - Phone:704-756-6553
Mailing Address - Fax:
Practice Address - Street 1:4221 CHATTERLEIGH DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8102
Practice Address - Country:US
Practice Address - Phone:704-756-6553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC167822251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health