Healthcare Provider Details

I. General information

NPI: 1275792327
Provider Name (Legal Business Name): ANGEL STAR OF DURHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

110 SCOTT AVE SUITE A
HIGH POINT NC
27262-7834
US

IV. Provider business mailing address

110 SCOTT AVE SUITE A
HIGH POINT NC
27262-7834
US

V. Phone/Fax

Practice location:
  • Phone: 336-889-3372
  • Fax: 336-889-3371
Mailing address:
  • Phone: 336-889-3372
  • Fax: 336-889-3371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC1481
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier6601776
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: VERONICA MCCLENDON
Title or Position: VICE PRESIDENT
Credential:
Phone: 740-549-1659