=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225382385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA HOMECARE VENTURES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2012
-----------------------------------------------------
Last Update Date | 10/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11330 VANSTORY DR
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-8143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-897-0496
-----------------------------------------------------
Fax | 704-897-0544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11330 VANSTORY DR
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-8143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-897-0496
-----------------------------------------------------
Fax | 704-897-0544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AGENCY OWNER
-----------------------------------------------------
Name | MR. DOMENIC DELLOSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-661-5686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------