Provider Demographics
NPI:1629298328
Name:TIFFANY HEALTHCARE, INC.
Entity Type:Organization
Organization Name:TIFFANY HEALTHCARE, INC.
Other - Org Name:LOUISBURG GARDENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:COLLETTE
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-946-6617
Mailing Address - Street 1:2294 GALLBERRY RD
Mailing Address - Street 2:PO BOX 1785
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-9178
Mailing Address - Country:US
Mailing Address - Phone:252-946-6617
Mailing Address - Fax:252-946-2313
Practice Address - Street 1:844 HWY 39 SOUTH
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549
Practice Address - Country:US
Practice Address - Phone:252-946-6617
Practice Address - Fax:525-946-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL035013305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804841Medicaid