MEDICARE: FAYETTEVILLE NC HOMECARE 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	385H00000X	Respite Care	HC4695	NC
2	253Z00000X	In Home Supportive Care Agency	HC4695	NC

General Provider Information

NPI Number	:	1679067854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTEVILLE NC HOMECARE LLC

Provider Business Mailing Address
First Line	:	230 WINSLOW ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5516
Country	:	US
Telephone Number	:	910-500-6955
Fax Number	:	910-500-6956

Provider Business Practice Location Address
First Line	:	230 WINSLOW ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5516
Country	:	US
Telephone Number	:	910-500-6955
Fax Number	:	910-500-6956

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MR. WILLIAM MATTHEW GORE
Credential	:
Telephone Number	:	910-500-6955

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	02/02/2026

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