Healthcare Provider Details

I. General information

NPI: 1275164196
Provider Name (Legal Business Name): ANNIE'S HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1784 HERITAGE CENTER DR STE 204-H
WAKE FOREST NC
27587-3989
US

IV. Provider business mailing address

1784 HERITAGE CENTER DR STE 204-H
WAKE FOREST NC
27587-3989
US

V. Phone/Fax

Practice location:
  • Phone: 919-426-2146
  • Fax:
Mailing address:
  • Phone: 919-426-2146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. ORLANDER A. BULLOCK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 919-426-2146