Provider Demographics
NPI:1215134309
Name:ADVANCED HOME CARE INC
Entity type:Organization
Organization Name:ADVANCED HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:KALBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-878-8824
Mailing Address - Street 1:PO BOX 18049
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27419-8049
Mailing Address - Country:US
Mailing Address - Phone:336-878-8950
Mailing Address - Fax:336-878-8883
Practice Address - Street 1:105 JACK WHITE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664
Practice Address - Country:US
Practice Address - Phone:423-378-7330
Practice Address - Fax:800-311-7783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TN0000029633336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ032329Medicaid
VA1215134309Medicaid
FA0301553OtherDEA
TN1455207Medicaid