Healthcare Provider Details

I. General information

NPI: 1679851356
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 07/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 GLENWOOD AVE SUITE 160
RALEIGH NC
27608-1043
US

IV. Provider business mailing address

2626 GLENWOOD AVE SUITE 160
RALEIGH NC
27608-1043
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-9565
  • Fax: 919-781-9564
Mailing address:
  • Phone: 919-781-9564
  • Fax: 919-781-9564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0542
License Number StateNC

VIII. Authorized Official

Name: MS. EMILY DNISTRAN
Title or Position: SENIOR STAFFING MANAGER
Credential:
Phone: 919-781-9565