Provider Demographics
NPI:1952929408
Name:COMPLETE WELL-CARE SOURCE LLC
Entity Type:Organization
Organization Name:COMPLETE WELL-CARE SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:VAUGHTERS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-682-8968
Mailing Address - Street 1:1320 LANDSDOWN DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-7373
Mailing Address - Country:US
Mailing Address - Phone:980-330-3432
Mailing Address - Fax:
Practice Address - Street 1:1320 LANDSDOWN DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-7373
Practice Address - Country:US
Practice Address - Phone:980-330-3432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1346879434Medicaid