Basic Information
| Provider Information | |||||||||
| NPI: | 1124302906 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUPPLEMENTAL HEALTHCARE STAFFING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 CECIL ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277073232 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2626 GLENWOOD AVE | ||||||||
| Address2: | SUITE160 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276081043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197819565 | ||||||||
| FaxNumber: | 9197819564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2011 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | ATHENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | RESPIRATORY THEARPIST | ||||||||
| AuthorizedOfficialTelephone: | 9196989253 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | A-3203 | NC | Y | Agencies | Nursing Care |
No ID Information.