MEDICARE: NURSE630 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	163WH0200X	Home Health Registered Nurse
2	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1841855582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NURSE630 LLC

Provider Business Mailing Address
First Line	:	429 N IVESTOR CT
Second Line	:
City	:	INMAN
State	:	SC
Zip	:	29349-7213
Country	:	US
Telephone Number	:	404-821-7210
Fax Number	:

Provider Business Practice Location Address
First Line	:	3505 PELHAM RD STE B
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-4154
Country	:	US
Telephone Number	:	864-670-5267
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ DIRECTOR
Name	:	TYKEBA WILLIAMS
Credential	:
Telephone Number	:	864-670-5267

Provider Enumeration Date	:	05/08/2019
Last Update Date	:	05/08/2019

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