Provider Demographics
NPI:1679975353
Name:WESCARE PROFESSIONAL SERVICES, LLC.
Entity Type:Organization
Organization Name:WESCARE PROFESSIONAL SERVICES, LLC.
Other - Org Name:MCTAVISH HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-272-8335
Mailing Address - Street 1:10 OAK BRANCH DR STE A
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-2995
Mailing Address - Country:US
Mailing Address - Phone:336-272-8335
Mailing Address - Fax:336-272-8339
Practice Address - Street 1:236 MCTAVISH LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-448-5676
Practice Address - Fax:336-272-8339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-034-329251S00000X, 320800000X
320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-034-329OtherLICENSE
NC3418297Medicaid