=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316219280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HOME CARE OF ROBESON COUNTY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2012
-----------------------------------------------------
Last Update Date | 05/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 PREMIERE PLZ
-----------------------------------------------------
City | WHITEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28472-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-918-0775
-----------------------------------------------------
Fax | 252-937-2647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 655 BRAWLEY SCHOOL RD SUITE 200
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-9125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-664-2876
-----------------------------------------------------
Fax | 704-664-1306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF LEGAL AFFAIRS
-----------------------------------------------------
Name | JESSICA KLEBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-664-2876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | HC4028
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------