Healthcare Provider Details

I. General information

NPI: 1043705502
Provider Name (Legal Business Name): C AND C LOVING HEART HEALTH CARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5122 CREST HAVEN WAY
PERRY HALL MD
21128
US

IV. Provider business mailing address

5122 CREST HAVEN WAY
PERRY HALL MD
21128-9793
US

V. Phone/Fax

Practice location:
  • Phone: 410-256-5710
  • Fax: 410-256-6052
Mailing address:
  • Phone: 410-256-5710
  • Fax: 410-256-6052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberR158240
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. CHRISTIE SIMON-WATERMAN
Title or Position: OWNER/ADMINISTRATOR
Credential: CRNP
Phone: 443-867-7471