Provider Demographics
NPI:1720273147
Name:HOMECARE MEDICAL GROUPS LLC
Entity Type:Organization
Organization Name:HOMECARE MEDICAL GROUPS LLC
Other - Org Name:HOMECARE MEDICAL GROUPS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-494-2207
Mailing Address - Street 1:10429 LIGON MILL RD
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4987
Mailing Address - Country:US
Mailing Address - Phone:919-556-7500
Mailing Address - Fax:888-891-4170
Practice Address - Street 1:10429 LIGON MILL RD
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4987
Practice Address - Country:US
Practice Address - Phone:919-556-7500
Practice Address - Fax:888-891-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251300000X, 251B00000X, 251C00000X, 251G00000X, 251S00000X, 252Y00000X, 343900000X
NC000000332B00000X, 332BN1400X, 332BX2000X, 332U00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251G00000XAgenciesHospice Care, Community Based
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332U00000XSuppliersHome Delivered Meals
No335E00000XSuppliersProsthetic/Orthotic Supplier
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7790000Medicaid
NCBREAST PROSTHETICSOtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS & PEDORTHICS
NCCERTIFIED PEDORTHISTOtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS & PEDORTHICS
NCFEDERALLY ACCREDITEDOtherHEALTHCARE QUALITY ASSOCIATION ON ACCREDITATION
NC7790000Medicaid