Healthcare Provider Details

I. General information

NPI: 1699050971
Provider Name (Legal Business Name): GOLDEN GATES HOMECARE AGENCY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 VALENCIA DR SUITE 165
JACKSONVILLE NC
28546-6311
US

IV. Provider business mailing address

200 VALENCIA DR SUITE 165
JACKSONVILLE NC
28546-6311
US

V. Phone/Fax

Practice location:
  • Phone: 910-388-6976
  • Fax:
Mailing address:
  • Phone: 910-388-6976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC4466
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberHC4466
License Number StateNC

VIII. Authorized Official

Name: MRS. LINDA MOORE CANADY
Title or Position: MEMBER/PRESIDENT
Credential:
Phone: 910-388-6976