Provider Demographics
NPI:1134889140
Name:FORTUNE HEART OF NORTH CAROLINA HOME CARE LLC
Entity type:Organization
Organization Name:FORTUNE HEART OF NORTH CAROLINA HOME CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BREONA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-584-0744
Mailing Address - Street 1:3117 WHITING AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1648
Mailing Address - Country:US
Mailing Address - Phone:980-306-4777
Mailing Address - Fax:
Practice Address - Street 1:3117 WHITING AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-1648
Practice Address - Country:US
Practice Address - Phone:980-306-4777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-19
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care