MEDICARE: MGA HOME HEALTHCARE FAYETTEVILLE, 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	251J00000X	Nursing Care Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518613330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MGA HOME HEALTHCARE FAYETTEVILLE, LLC

Provider Business Mailing Address
First Line	:	3400 WALSH PKWY STE 248
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-1642
Country	:	US
Telephone Number	:	910-839-0239
Fax Number	:	910-900-0915

Provider Business Practice Location Address
First Line	:	3400 WALSH PKWY STE 248
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-1642
Country	:	US
Telephone Number	:	910-839-0239
Fax Number	:	910-900-0915

Authorized Official
Title or Position	:	VP, OPERATIONS
Name	:	WENDY CHAVEZ
Credential	:	MSN, RN
Telephone Number	:	910-839-0239

Provider Enumeration Date	:	03/02/2022
Last Update Date	:	03/02/2022

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