Healthcare Provider Details

I. General information

NPI: 1093299745
Provider Name (Legal Business Name): CLASSIC CARE HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ANNIE PARKER CIR
SMITHFIELD NC
27577-3976
US

IV. Provider business mailing address

101 ANNIE PARKER CIR
SMITHFIELD NC
27577-3976
US

V. Phone/Fax

Practice location:
  • Phone: 919-934-8976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. VISHRUT PATEL
Title or Position: COO
Credential:
Phone: 757-285-6001