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General NPI Number Information
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NPI Number | 1104196807
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Entity Type | Organization
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Legal Business Name | GATE CITY OF BURLINGTON
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Dates
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Enumeration Date | 01/11/2012
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Last Update Date | 01/11/2012
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Provider Practice Location Address
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Address Line | 2603 HOLLY HILL STREET
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City | BURLINGTON
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State | NC
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Zip | 27215
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Country | US
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Telephone | 336-270-7061
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Fax |
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Provider Business Mailing Address
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Address Line | 2603 HOLLY HILL ST
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City | BURLINGTON
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State | NC
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Zip | 27215-5156
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Country | US
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Telephone | 336-270-7061
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACKIE CHAMBERS
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Credential |
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Telephone | 336-270-7061
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | HC4039
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | HC4039
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License Number State | NC
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