Provider Demographics
NPI:1124646328
Name:COMPLETE WELL-CARE SOURCE LLC
Entity type:Organization
Organization Name:COMPLETE WELL-CARE SOURCE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:VAUGHTERS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-682-8968
Mailing Address - Street 1:1320 LANDSDOWN DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-7373
Mailing Address - Country:US
Mailing Address - Phone:980-305-2003
Mailing Address - Fax:980-340-3432
Practice Address - Street 1:512 KLUMAC RD STE 9
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-6752
Practice Address - Country:US
Practice Address - Phone:980-305-2003
Practice Address - Fax:980-243-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-14
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124646328Medicaid
NC1952929408Medicaid