MEDICARE: EXPRESS SUPPORT GROUP 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	251B00000X	Case Management Agency
2	251C00000X	Developmentally Disabled Services Day Training Agency
3	251S00000X	Community/Behavioral Health Agency
4	253Z00000X	In Home Supportive Care Agency
5	3747P1801X	Personal Care Attendant	HC4298	NC

General Provider Information

NPI Number	:	1700010220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPRESS SUPPORT GROUP LLC

Provider Business Mailing Address
First Line	:	1801 SAINT ALBANS DR STE G
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-6286
Country	:	US
Telephone Number	:	919-876-4949
Fax Number	:	919-876-4946

Provider Business Practice Location Address
First Line	:	1801 SAINT ALBANS DR STE G
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-6286
Country	:	US
Telephone Number	:	919-876-4949
Fax Number	:	919-876-4946

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. PATRICK IFEANYI OGBONNA
Credential	:
Telephone Number	:	919-876-4949

Provider Enumeration Date	:	05/12/2009
Last Update Date	:	08/01/2013

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