=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275249880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASECONDHOMECARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2023
-----------------------------------------------------
Last Update Date | 01/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 SKINNER DR
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27610-8011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-758-4078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 NEW BERN AVE UNIT 24963
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27611-0120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-758-4078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. LATINA MARIE COSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-758-4078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------