Provider Demographics
NPI:1598181430
Name:SERVANT'S HEART
Entity Type:Organization
Organization Name:SERVANT'S HEART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/QP
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-286-6400
Mailing Address - Street 1:532 N REGIONAL RD STE E
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-9057
Mailing Address - Country:US
Mailing Address - Phone:336-286-6400
Mailing Address - Fax:336-664-1212
Practice Address - Street 1:1921 NEW GARDEN RD APT K107
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2250
Practice Address - Country:US
Practice Address - Phone:336-282-9025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-773253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care