Provider Demographics
NPI:1982924726
Name:SPC HOME HEALTH LLC
Entity Type:Organization
Organization Name:SPC HOME HEALTH LLC
Other - Org Name:SPC HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAKISHA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:BREWINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-658-8525
Mailing Address - Street 1:P.O. BOX 3385
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-0385
Mailing Address - Country:US
Mailing Address - Phone:910-395-8039
Mailing Address - Fax:910-395-8381
Practice Address - Street 1:4910 RANDALL PARKWAY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2827
Practice Address - Country:US
Practice Address - Phone:910-395-8039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC4101251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6602388Medicaid