Healthcare Provider Details

I. General information

NPI: 1396010781
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1759 W 5TH ST
WASHINGTON NC
27889-4003
US

IV. Provider business mailing address

1759 W 5TH ST
WASHINGTON NC
27889-4003
US

V. Phone/Fax

Practice location:
  • Phone: 252-412-8669
  • Fax:
Mailing address:
  • Phone: 252-412-8669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number8219
License Number StateNC

VIII. Authorized Official

Name: EMILY DRISTRAN
Title or Position: SENIOR STAFFING MANGER
Credential:
Phone: 919-781-9565