Provider Demographics
NPI:1750661492
Name:MYRIAD HOMECARE AGENCY, LLC
Entity Type:Organization
Organization Name:MYRIAD HOMECARE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDGETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-673-6910
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:ROLESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27571-0363
Mailing Address - Country:US
Mailing Address - Phone:919-673-6910
Mailing Address - Fax:
Practice Address - Street 1:262 SOUTHTOWN CIR STE C
Practice Address - Street 2:
Practice Address - City:ROLESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27571-9593
Practice Address - Country:US
Practice Address - Phone:919-673-6910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
NCHC4430385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care