Healthcare Provider Details

I. General information

NPI: 1659973998
Provider Name (Legal Business Name): EAST WAKE HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FOREST DR
KNIGHTDALE NC
27545-9603
US

IV. Provider business mailing address

101 FOREST DR STE B
KNIGHTDALE NC
27545-9603
US

V. Phone/Fax

Practice location:
  • Phone: 919-307-9314
  • Fax:
Mailing address:
  • Phone: 757-759-8891
  • 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 Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: KYARRA ROGERS
Title or Position: RN/ AGENCY DIRECTOR
Credential:
Phone: 757-759-8891