=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992023436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUILLEN ENTERPRISES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2010
-----------------------------------------------------
Last Update Date | 05/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2025-C MARTIN LUTHER KING JR. DRIVE SUITE C
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-218-8757
-----------------------------------------------------
Fax | 336-510-1499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2025-C MARTIN LUTHER KING JR. DRIVE SUITE C
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-218-8757
-----------------------------------------------------
Fax | 336-510-1499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DIANE E QUILLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-218-8157
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HC4073
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------