Provider Demographics
NPI:1972501807
Name:HEARTHSIDE HOME CARE INC.
Entity Type:Organization
Organization Name:HEARTHSIDE HOME CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-723-4858
Mailing Address - Street 1:PO BOX 9383
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27429-0383
Mailing Address - Country:US
Mailing Address - Phone:336-723-4858
Mailing Address - Fax:
Practice Address - Street 1:505 STATE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-5658
Practice Address - Country:US
Practice Address - Phone:336-723-4858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2393251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601151Medicaid