Provider Demographics
NPI:1265526016
Name:AGAPE HEALTHCARE SYSTEMS CORP
Entity type:Organization
Organization Name:AGAPE HEALTHCARE SYSTEMS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-537-2473
Mailing Address - Street 1:1015 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-3722
Mailing Address - Country:US
Mailing Address - Phone:252-537-2473
Mailing Address - Fax:888-315-1326
Practice Address - Street 1:1015 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-3722
Practice Address - Country:US
Practice Address - Phone:252-537-2473
Practice Address - Fax:888-315-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X
NCLH00422291U00000X
NCHC2914251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601634Medicaid