Provider Demographics
NPI:1700019486
Name:GENESIS OF CAROLINAS HOME CARE, LLC
Entity Type:Organization
Organization Name:GENESIS OF CAROLINAS HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:DEVONNE
Authorized Official - Last Name:SHANKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-207-3947
Mailing Address - Street 1:5736 NORTH TRYON STREET SUITE 128
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-6891
Mailing Address - Country:US
Mailing Address - Phone:980-207-3947
Mailing Address - Fax:980-207-3956
Practice Address - Street 1:5736 NORTH TRYON STREET SUITE 128
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-6891
Practice Address - Country:US
Practice Address - Phone:980-207-3947
Practice Address - Fax:980-207-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
NC100027253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care