Basic Information
Provider Information | |||||||||
NPI: | 1861589194 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OAK HEALTH CARE INVESTORS OF NORTH CAROLINA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAURELS OF FOREST GLENN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1101 HARTWELL ST | ||||||||
Address2: |   | ||||||||
City: | GARNER | ||||||||
State: | NC | ||||||||
PostalCode: | 275293675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197728888 | ||||||||
FaxNumber: | 9197728436 | ||||||||
Practice Location | |||||||||
Address1: | 1101 HARTWELL ST | ||||||||
Address2: |   | ||||||||
City: | GARNER | ||||||||
State: | NC | ||||||||
PostalCode: | 275293675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197728888 | ||||||||
FaxNumber: | 9197728436 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 10/05/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATTON | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6147948800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | NH0506 | NC | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
ID | Type | State | Issuer | Description | 0082M | 01 | NC | BC/BS # | OTHER | 345389 | 05 | NC |   | MEDICAID | NH0506 | 01 | NC | NH LICENSE # | OTHER | 7105588 | 01 | NC | UNITED HEALTH CARE ID # | OTHER | 923173 | 01 | NC | FACILITY ID # | OTHER |