Provider Demographics
NPI:1194966440
Name:PELHAM HOME HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:PELHAM HOME HEALTH SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RNC, BSN
Authorized Official - Phone:910-630-6757
Mailing Address - Street 1:PO BOX 9754
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-9091
Mailing Address - Country:US
Mailing Address - Phone:910-630-6757
Mailing Address - Fax:910-884-9806
Practice Address - Street 1:315 W BROAD ST
Practice Address - Street 2:
Practice Address - City:SAINT PAULS
Practice Address - State:NC
Practice Address - Zip Code:28384-1535
Practice Address - Country:US
Practice Address - Phone:910-865-3368
Practice Address - Fax:910-865-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2268251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6600905Medicaid