=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104121862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICAH'S HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2011
-----------------------------------------------------
Last Update Date | 01/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2444 COMMERCE RD STE 232
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28546-7560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-605-6406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 GEORGETOWN RD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28540-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-605-6406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAULETTE WASHINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-605-6406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number | HC4279
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------