MEDICARE: COMMUNITY SUPPORT PROFESSIONALS,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	8300728H	NC
2	251B00000X	Case Management Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174566905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY SUPPORT PROFESSIONALS,LLC

Provider Business Mailing Address
First Line	:	1606 WELLINGTON AVE UNITC
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-7704
Country	:	US
Telephone Number	:	910-799-4505
Fax Number	:	910-799-4345

Provider Business Practice Location Address
First Line	:	1606 WELLINGTON AVE UNITC
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-7704
Country	:	US
Telephone Number	:	910-799-4505
Fax Number	:	910-799-4345

Authorized Official
Title or Position	:	CEO
Name	:	CHARLES CHRISTOPHER CREECH
Credential	:
Telephone Number	:	910-799-4505

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	02/04/2009

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