MEDICARE: PROFESSIONAL CARE HOME HEALTH SERVICES

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	251J00000X	Nursing Care Agency	0000000	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1234567	OTHER	NC	PDN

General Provider Information

NPI Number	:	1982856340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL CARE HOME HEALTH SERVICES

Provider Business Mailing Address
First Line	:	3137 AMITY COURT
Second Line	:	SUITE 400
City	:	CHARLOTTE
State	:	NC
Zip	:	28215
Country	:	US
Telephone Number	:	704-536-7326
Fax Number	:	704-536-7147

Provider Business Practice Location Address
First Line	:	3137 AMITY COURT
Second Line	:	SUITE 400
City	:	CHARLOTTE
State	:	NC
Zip	:	28215
Country	:	US
Telephone Number	:	704-536-7326
Fax Number	:	704-536-7147

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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