Healthcare Provider Details

I. General information

NPI: 1255141958
Provider Name (Legal Business Name): DREAM HOME PROFESSIONAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 GENTLE STREAM LN
RALEIGH NC
27603-4868
US

IV. Provider business mailing address

312 GENTLE STREAM LN
RALEIGH NC
27603-4868
US

V. Phone/Fax

Practice location:
  • Phone: 940-631-4405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: AMY DAVIS
Title or Position: OWNER
Credential:
Phone: 940-631-4405