Basic Information
| Provider Information | |||||||||
| NPI: | 1316913569 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOME HEALTH PROFESSIONALS OF FORSYTH, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOME HEALTH PROFESSIONALS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2599 LANDMARK DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367603634 | ||||||||
| FaxNumber: | 3367687456 | ||||||||
| Practice Location | |||||||||
| Address1: | 2599 LANDMARK DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367603634 | ||||||||
| FaxNumber: | 3367687456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELLEDGE | ||||||||
| AuthorizedOfficialFirstName: | NICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3366798852 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HC0005 | NC | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 3407187 | 05 | NC | MEDICAID |