Healthcare Provider Details

I. General information

NPI: 1285711879
Provider Name (Legal Business Name): ST MARYS HOME CARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 VILLAGE DR
FAYETTEVILLE NC
28304-4551
US

IV. Provider business mailing address

3401 VILLAGE DR
FAYETTEVILLE NC
28304-4551
US

V. Phone/Fax

Practice location:
  • Phone: 910-433-4477
  • Fax: 910-920-3179
Mailing address:
  • Phone: 910-433-4477
  • Fax: 910-920-3179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0000
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberHC2557
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNC

VIII. Authorized Official

Name: MRS. RASHAE N WILLIAMS
Title or Position: CEO
Credential: BS
Phone: 910-433-4477