Provider Demographics
NPI:1700010220
Name:EXPRESS SUPPORT GROUP LLC
Entity Type:Organization
Organization Name:EXPRESS SUPPORT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:IFEANYI
Authorized Official - Last Name:OGBONNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-876-4949
Mailing Address - Street 1:1801 SAINT ALBANS DR STE G
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6286
Mailing Address - Country:US
Mailing Address - Phone:919-876-4949
Mailing Address - Fax:919-876-4946
Practice Address - Street 1:1801 SAINT ALBANS DR STE G
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6286
Practice Address - Country:US
Practice Address - Phone:919-876-4949
Practice Address - Fax:919-876-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251C00000X, 251S00000X, 253Z00000X
NCHC42983747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive Care