Healthcare Provider Details

I. General information

NPI: 1639135536
Provider Name (Legal Business Name): JANICE L. WHITLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MOSS SPRINGS RD SUITE-A
ALBEMARLE NC
28001-5140
US

IV. Provider business mailing address

105 MOSS SPRINGS RD SUITE-A
ALBEMARLE NC
28001-5140
US

V. Phone/Fax

Practice location:
  • Phone: 704-983-6770
  • Fax: 704-983-6160
Mailing address:
  • Phone: 704-983-6770
  • Fax: 704-983-6160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier7795213
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MRS. JANICE L WHITLEY
Title or Position: OWNER
Credential: COF,CFTS
Phone: 704-983-6770