Healthcare Provider Details

I. General information

NPI: 1043683188
Provider Name (Legal Business Name): MOUNT EAGLE HEALTH CARE - CLEMMONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2554 LEWISVILLE CLEMMONS RD # 306
CLEMMONS NC
27012-8110
US

IV. Provider business mailing address

2554 LEWISVILLE CLEMMONS RD # 306
CLEMMONS NC
27012-8110
US

V. Phone/Fax

Practice location:
  • Phone: 336-934-4227
  • Fax:
Mailing address:
  • Phone: 336-934-4227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberHC1587
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberHC1587
License Number StateNC

VIII. Authorized Official

Name: BAHATI N SIMTAJI
Title or Position: DIRECTOR
Credential:
Phone: 336-934-4227