Basic Information
| Provider Information | |||||||||
| NPI: | 1043370737 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF BLADEN OFFICE OF AUDITOR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLADEN COUNTY HOME HEALTH AGENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 189 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283370189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108626901 | ||||||||
| FaxNumber: | 9108626886 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MERCER ROAD | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283370189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108626901 | ||||||||
| FaxNumber: | 9108626886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 12/11/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REGISTER | ||||||||
| AuthorizedOfficialFirstName: | DJUANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9108726209 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | HC0481 | NC | N | Agencies | Case Management | 251E00000X | HC0481 | NC | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 00707 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 3407097 | 05 | NC | MEDICAID | 34D0655367 | 01 | NC | CLIA | OTHER |