MEDICARE: TIJUANA DEL ROYA WHITE

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	253Z00000X	In Home Supportive Care Agency	HC5490	NC

General Provider Information

NPI Number	:	1912537523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIJUANA DEL ROYA WHITE

Provider Business Mailing Address
First Line	:	2413 ROBESON ST STE 1
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-5500
Country	:	US
Telephone Number	:	910-491-3069
Fax Number	:	910-229-2143

Provider Business Practice Location Address
First Line	:	2413 ROBESON ST STE 1
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-5500
Country	:	US
Telephone Number	:	109-491-3069
Fax Number	:	910-229-2143

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	05/29/2020

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