Healthcare Provider Details

I. General information

NPI: 1386221810
Provider Name (Legal Business Name): ETHEREAL HOME MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216 W MEADOWVIEW RD STE 264
GREENSBORO NC
27407-3406
US

IV. Provider business mailing address

3902 WOODBERRY LAKE DR
GREENSBORO NC
27455-0944
US

V. Phone/Fax

Practice location:
  • Phone: 336-303-2778
  • Fax:
Mailing address:
  • Phone: 336-303-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LATINA WILLIAMS
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 336-303-2778