MEDICARE: FORTUNE HEART OF NORTH CAROLINA HOME CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1134889140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORTUNE HEART OF NORTH CAROLINA HOME CARE LLC

Provider Business Mailing Address
First Line	:	3117 WHITING AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1648
Country	:	US
Telephone Number	:	980-306-4777
Fax Number	:

Provider Business Practice Location Address
First Line	:	3117 WHITING AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1648
Country	:	US
Telephone Number	:	980-306-4777
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BREONA BLACKWELL
Credential	:
Telephone Number	:	864-584-0744

Provider Enumeration Date	:	12/19/2021
Last Update Date	:	02/24/2024

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