Healthcare Provider Details

I. General information

NPI: 1225343395
Provider Name (Legal Business Name): AGELESS HEART HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 S 13TH ST
ERWIN NC
28339-2634
US

IV. Provider business mailing address

708 S 13TH ST
ERWIN NC
28339-2634
US

V. Phone/Fax

Practice location:
  • Phone: 910-292-0173
  • Fax: 910-292-0174
Mailing address:
  • Phone: 910-230-0555
  • Fax: 910-230-0550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberHC2965
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License NumberHC2965
License Number StateNC

VIII. Authorized Official

Name: JOHNATHAUN LEE
Title or Position: PRESIDENT
Credential:
Phone: 910-230-0555