MEDICARE: WHITE SWAN HOME HEALTH CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	HC4238	NC
2	253Z00000X	In Home Supportive Care Agency	HC4238	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HC4238	OTHER	NC	NC DHHS

General Provider Information

NPI Number	:	1467792234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE SWAN HOME HEALTH CARE, LLC

Provider Business Mailing Address
First Line	:	4173 HEARTHSIDE DRIVE
Second Line	:	104
City	:	WILMINGTON
State	:	NC
Zip	:	28412-8335
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 N BROAD STREET
Second Line	:	1-A
City	:	ANGIER
State	:	NC
Zip	:	27501-0000
Country	:	US
Telephone Number	:	919-799-2019
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOHNATHAUN LEE
Credential	:
Telephone Number	:	954-479-9856

Provider Enumeration Date	:	02/15/2013
Last Update Date	:	06/19/2013

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