Provider Demographics
NPI:1609996446
Name:ETCARE HOME QUALITY MANAGEMENT, INC
Entity Type:Organization
Organization Name:ETCARE HOME QUALITY MANAGEMENT, INC
Other - Org Name:LAKE WACCAMAW SENIOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:BIGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-521-5550
Mailing Address - Street 1:PO BOX 1179
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-1179
Mailing Address - Country:US
Mailing Address - Phone:910-521-5550
Mailing Address - Fax:910-521-3335
Practice Address - Street 1:206 WANNISH AVE
Practice Address - Street 2:
Practice Address - City:LAKE WACCAMAW
Practice Address - State:NC
Practice Address - Zip Code:28450
Practice Address - Country:US
Practice Address - Phone:910-646-3153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-024-009310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805431Medicaid