Basic Information
| Provider Information | |||||||||
| NPI: | 1831194547 | ||||||||
| 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: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 109 EXETER ST | ||||||||
| Address2: | |||||||||
| City: | MANTEO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279549400 | ||||||||
| 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: | 06/17/2005 | ||||||||
| LastUpdateDate: | 01/08/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| 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 | 251G00000X | HC0494 | NC | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 4106582 | 01 | NC | MAMSI HOSPICE | OTHER | 3401584 | 05 | NC | MEDICAID | 001E7 | 01 | NC | BC-BS HOSPICE | OTHER |