MEDICARE: MS. BETTY ODESSIA DOVER

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
2	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1316514490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BETTY ODESSIA DOVER

Provider Business Mailing Address
First Line	:	3010 MONROE RD STE 107A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7533
Country	:	US
Telephone Number	:	704-963-6961
Fax Number	:

Provider Business Practice Location Address
First Line	:	3010 MONROE RD STE 107A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7533
Country	:	US
Telephone Number	:	704-963-6961
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2021
Last Update Date	:	07/01/2021

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