=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669518981
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPE I
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 COLONY RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28112-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-225-0584
-----------------------------------------------------
Fax | 704-292-1915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 ROBIN DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28112-6478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-225-0584
-----------------------------------------------------
Fax | 704-292-1915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEFF MASSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-283-4295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | MHL090049
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------