Provider Demographics
NPI:1659950442
Name:MGA HOME HEALTHCARE FAYETTEVILLE, LLC
Entity Type:Organization
Organization Name:MGA HOME HEALTHCARE FAYETTEVILLE, LLC
Other - Org Name:MGA HOMECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEATY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-200-9015
Mailing Address - Street 1:4700 HOMEWOOD CT STE 310
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5732
Mailing Address - Country:US
Mailing Address - Phone:919-241-7781
Mailing Address - Fax:
Practice Address - Street 1:4700 HOMEWOOD CT STE 310
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5732
Practice Address - Country:US
Practice Address - Phone:919-241-7781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC6067Medicaid
NCHC6297Medicaid
NCHC6135Medicaid