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General NPI Number Information
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NPI Number | 1962194357
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Entity Type | Organization
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Legal Business Name | EXECUTIVE LEAGUE INC
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Dates
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Enumeration Date | 05/23/2023
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Last Update Date | 05/08/2024
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Provider Practice Location Address
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Address Line | 1109 E WENDOVER AVE STE A
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City | GREENSBORO
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State | NC
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Zip | 27405-6778
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Country | US
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Telephone | 336-907-6163
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 E WENDOVER AVE STE B
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City | GREENSBORO
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State | NC
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Zip | 27405-6849
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Country | US
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Telephone | 336-907-6163
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CLARENCE MACK
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Credential |
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Telephone | 336-907-6163
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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