Basic Information
Provider Information | |||||||||
NPI: | 1285630384 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DARE COUNTY ADMINISTRATIVE OFFICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DARE HOME HEALTH AND DARE HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 109 EXETER ST. | ||||||||
Address2: | P.O. BOX 1000 | ||||||||
City: | MANTEO | ||||||||
State: | NC | ||||||||
PostalCode: | 27954 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2524755028 | ||||||||
FaxNumber: | 2524739814 | ||||||||
Practice Location | |||||||||
Address1: | 109 EXETER ST | ||||||||
Address2: |   | ||||||||
City: | MANTEO | ||||||||
State: | NC | ||||||||
PostalCode: | 279549400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2524755028 | ||||||||
FaxNumber: | 2524739814 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2005 | ||||||||
LastUpdateDate: | 01/08/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURRUS | ||||||||
AuthorizedOfficialFirstName: | JACCIE | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | HEALTH AND HUMAN SERVICES DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2524755076 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DARE COUNTY ADMINISTRATIVE OFFICES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HC0494 | NC | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 3407074 | 05 | NC |   | MEDICAID | 00738 | 01 | NC | BC-BS | OTHER | 3106582 | 01 | NC | MAMSI | OTHER |