Provider Demographics
NPI:1851042295
Name:FOGODEMISA HOME CARE LLC
Entity Type:Organization
Organization Name:FOGODEMISA HOME CARE LLC
Other - Org Name:FOGODEMISA HOME CARE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GOLD
Authorized Official - Middle Name:E
Authorized Official - Last Name:OMOGBEHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-670-1061
Mailing Address - Street 1:1308 SNOWY EGRET DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-3227
Mailing Address - Country:US
Mailing Address - Phone:910-476-3859
Mailing Address - Fax:
Practice Address - Street 1:2665 JOHN SMITH RD STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-2623
Practice Address - Country:US
Practice Address - Phone:910-476-3859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-18
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty