=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609547405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | V&D'S SACRED PLACE LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2021
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3434 EDWARDS MILL RD STE 112-215
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27612-4275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-746-4155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3434 EDWARDS MILL RD STE 112-215
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27612-4275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-746-4155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. TANISHA MARIE BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-746-4155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------