Provider Demographics
NPI:1639825458
Name:MGA HOME HEALTHCARE FAYETTEVILLE, LLC
Entity Type:Organization
Organization Name:MGA HOME HEALTHCARE FAYETTEVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, RN
Authorized Official - Phone:704-200-9015
Mailing Address - Street 1:1100 SOUTH STRATFORD RD
Mailing Address - Street 2:BLDG C SUITE 301
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-280-0435
Mailing Address - Fax:336-217-8746
Practice Address - Street 1:1100 SOUTH STRATFORD RD
Practice Address - Street 2:BLDG C SUITE 301
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-280-0435
Practice Address - Fax:336-217-8746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC6135Medicaid
NCHC6067Medicaid