Healthcare Provider Details

I. General information

NPI: 1215423777
Provider Name (Legal Business Name): BROADWAY HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 WINDEL DR STE 105
RALEIGH NC
27609
US

IV. Provider business mailing address

107 WINDEL DR STE 105
RALEIGH NC
27609-4471
US

V. Phone/Fax

Practice location:
  • Phone: 984-206-2600
  • Fax:
Mailing address:
  • Phone: 984-206-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: AVI BISTON
Title or Position: MANAGING MEMBER
Credential:
Phone: 984-206-2600