MEDICARE: MOUNT EAGLE HEALTH CARE GREENSBORO, 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	251E00000X	Home Health Agency	HC4420	NC
2	251F00000X	Home Infusion Agency	HC4420	NC
3	251J00000X	Nursing Care Agency	HC4420	NC
4	253Z00000X	In Home Supportive Care Agency	HC4420	NC
5	251S00000X	Community/Behavioral Health Agency	HC4420	NC

General Provider Information

NPI Number	:	1194192500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT EAGLE HEALTH CARE GREENSBORO, LLC

Provider Business Mailing Address
First Line	:	1 CENTERVIEW DR STE 203
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-3712
Country	:	US
Telephone Number	:	336-283-5191
Fax Number	:	336-499-6532

Provider Business Practice Location Address
First Line	:	1 CENTERVIEW DR STE 203
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-3712
Country	:	US
Telephone Number	:	336-283-5191
Fax Number	:	336-499-6532

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DOROTHY EDWARD SHALLUA
Credential	:	RN
Telephone Number	:	336-283-5191

Provider Enumeration Date	:	09/02/2015
Last Update Date	:	09/02/2015

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