Provider Demographics
NPI:1194156265
Name:DEEPLY ROOTED HOME CARE INCORPORATED
Entity type:Organization
Organization Name:DEEPLY ROOTED HOME CARE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-332-4409
Mailing Address - Street 1:124 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-3416
Mailing Address - Country:US
Mailing Address - Phone:252-332-4409
Mailing Address - Fax:252-332-5099
Practice Address - Street 1:124 MAIN ST E
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-3416
Practice Address - Country:US
Practice Address - Phone:252-332-4409
Practice Address - Fax:252-332-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2981253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408323Medicaid