Provider Demographics
NPI:1770160210
Name:MGA HOME HEALTHCARE FAYETTEVILLE, LLC
Entity type:Organization
Organization Name:MGA HOME HEALTHCARE FAYETTEVILLE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEATY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, RN
Authorized Official - Phone:704-200-9015
Mailing Address - Street 1:9101 KINGS PARADE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4068
Mailing Address - Country:US
Mailing Address - Phone:704-200-9015
Mailing Address - Fax:
Practice Address - Street 1:9101 KINGS PARADE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4068
Practice Address - Country:US
Practice Address - Phone:704-200-9015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC6135Medicaid
NCHC6067Medicaid
NCHC6297Medicaid