Provider Demographics
NPI:1205293313
Name:APPOINTED TO PROVIDE HOME CARE AGENCY
Entity type:Organization
Organization Name:APPOINTED TO PROVIDE HOME CARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARRIKA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-219-3495
Mailing Address - Street 1:4817 SPRUCE PEAK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-6559
Mailing Address - Country:US
Mailing Address - Phone:980-219-3495
Mailing Address - Fax:
Practice Address - Street 1:4817 SPRUCE PEAK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-6559
Practice Address - Country:US
Practice Address - Phone:980-219-3495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC372600000XMedicaid
NC372500000XMedicaid
NC374J00000XMedicaid
NC376K00000XMedicaid
NC373H00000XMedicaid
NC374U00000XMedicaid
NC3747A0650XMedicaid
NC3747P1801XMedicaid
NC376J00000XMedicaid