Healthcare Provider Details

I. General information

NPI: 1992930705
Provider Name (Legal Business Name): CANINE CABANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2009
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4717 S BLUE MARLIN WAY
NAGS HEAD NC
27959-9678
US

IV. Provider business mailing address

4717 S BLUE MARLIN WAY
NAGS HEAD NC
27959-9678
US

V. Phone/Fax

Practice location:
  • Phone: 252-441-7517
  • Fax: 252-441-7517
Mailing address:
  • Phone: 252-441-7517
  • Fax: 252-441-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNC

VIII. Authorized Official

Name: DR. GEORGEANNE HOEGERMAN
Title or Position: OWNER/ADMINISTRATOR
Credential: MD
Phone: 252-441-7517