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General NPI Number Information
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NPI Number | 1225343395
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Entity Type | Organization
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Legal Business Name | AGELESS HEART HEALTHCARE, INC
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Dates
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Enumeration Date | 08/13/2010
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Last Update Date | 06/14/2013
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Provider Practice Location Address
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Address Line | 708 S 13TH ST
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City | ERWIN
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State | NC
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Zip | 28339-2634
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Country | US
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Telephone | 910-292-0173
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Fax | 910-292-0174
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Provider Business Mailing Address
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Address Line | 708 S 13TH ST
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City | ERWIN
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State | NC
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Zip | 28339-2634
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Country | US
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Telephone | 910-230-0555
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Fax | 910-230-0550
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHNATHAUN LEE
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Credential |
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Telephone | 910-230-0555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number | HC2965
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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 | HC2965
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License Number State | NC
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