MEDICARE: SAFE SPACE IN-HOME SUPPORT 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1336073170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAFE SPACE IN-HOME SUPPORT LLC

Provider Business Mailing Address
First Line	:	6204 HARBURN FOREST DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-6902
Country	:	US
Telephone Number	:	704-287-2252
Fax Number	:

Provider Business Practice Location Address
First Line	:	6204 HARBURN FOREST DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-6902
Country	:	US
Telephone Number	:	704-287-2252
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL WAYNE SIMMONS
Credential	:
Telephone Number	:	704-287-2252

Provider Enumeration Date	:	06/09/2026
Last Update Date	:	06/09/2026

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Directions to “SAFE SPACE IN-HOME SUPPORT LLC ” Practice Location

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