Provider Demographics
NPI:1689738312
Name:LOVE GARDEN, LLC
Entity Type:Organization
Organization Name:LOVE GARDEN, LLC
Other - Org Name:LOVE GARDEN HEALTHCARE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:C
Authorized Official - Last Name:IHEANACHO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-988-2964
Mailing Address - Street 1:419 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-1847
Mailing Address - Country:US
Mailing Address - Phone:336-988-2964
Mailing Address - Fax:336-790-8555
Practice Address - Street 1:419 BENNETT ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-1847
Practice Address - Country:US
Practice Address - Phone:336-988-2964
Practice Address - Fax:336-790-8555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3594251E00000X
NCMH-041-783320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC061400OtherFACILITY ID:
NC3418269Medicaid
NC6601648Medicaid
NC8301659Medicaid
NC061380OtherFACILITY ID:
NC6604006Medicaid
NC8301748GMedicaid
NC8301659BMedicaid
NC8301748Medicaid