Basic Information
| Provider Information | |||||||||
| NPI: | 1235546623 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKE FOREST BAPTIST HEALTH CARE AT HOME, LLC | ||||||||
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| OtherOrganizationName: | WAKE FOREST BAPATIST HEALTHCARE A HOME, COMMUNITY CARE-WILKES, DISABLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 4060 | ||||||||
| Address2: | ATTN: REGULATORY | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281171157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046620416 | ||||||||
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| Practice Location | |||||||||
| Address1: | 56 BOONE TRAIL | ||||||||
| Address2: | |||||||||
| City: | NORTH WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286593515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366672208 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | COMBS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, LICENSURE | ||||||||
| AuthorizedOfficialTelephone: | 9138142013 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 253Z00000X | N | Agencies | In Home Supportive Care | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332U00000X | N | Suppliers | Home Delivered Meals | 385H00000X | N | Respite Care Facility | Respite Care | 171M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1235546623 | 05 | NC | MEDICAID |