Healthcare Provider Details

I. General information

NPI: 1992018352
Provider Name (Legal Business Name): MAYOS LOVING CARE ADULT GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 KRISTA LN
ROCKY MOUNT NC
27803-5228
US

IV. Provider business mailing address

105 KRISTA LN
ROCKY MOUNT NC
27803-5228
US

V. Phone/Fax

Practice location:
  • Phone: 252-973-8593
  • Fax: 252-407-4950
Mailing address:
  • Phone: 252-973-8593
  • Fax: 252-407-4950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberMHL064115
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberMHL064115
License Number StateNC

VIII. Authorized Official

Name: MR. SAMUEL CORMELIUS MAYO SR.
Title or Position: QP/CO-OWNER
Credential: LRT/CTRS
Phone: 252-281-7717