MEDICARE: PROFESSIONAL CARE HOME HEALTH

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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000000	OTHER	NC	DME-WINSTON

General Provider Information

NPI Number	:	1417109877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL CARE HOME HEALTH

Provider Business Mailing Address
First Line	:	2070 CLOVERDALE AVE
Second Line	:	SUITE C
City	:	WINSTON-SALEM
State	:	NC
Zip	:	28215-5765
Country	:	US
Telephone Number	:	336-725-0755
Fax Number	:

Provider Business Practice Location Address
First Line	:	2070 CLOVERDALE AVE
Second Line	:	SUITE C
City	:	WINSTON-SALEM
State	:	NC
Zip	:	28215-5765
Country	:	US
Telephone Number	:	336-725-0755
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TERESIA MEDLEY
Credential	:
Telephone Number	:	704-536-7326

Provider Enumeration Date	:	10/16/2008
Last Update Date	:	10/16/2008

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Directions to “PROFESSIONAL CARE HOME HEALTH ” Practice Location

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