MEDICARE: IDELLA'S CARE HOME

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	:	1669998001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDELLA'S CARE HOME

Provider Business Mailing Address
First Line	:	912 PRISTINE LN
Second Line	:
City	:	ROLESVILLE
State	:	NC
Zip	:	27571-9307
Country	:	US
Telephone Number	:	252-213-6081
Fax Number	:

Provider Business Practice Location Address
First Line	:	2912 LEE CT # 9A
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27834
Country	:	US
Telephone Number	:	252-213-6081
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EUNICE ESSIEN-HART
Credential	:
Telephone Number	:	252-213-6081

Provider Enumeration Date	:	08/17/2017
Last Update Date	:	08/10/2018

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