Provider Demographics
NPI:1285711879
Name:ST MARYS HOME CARE AGENCY
Entity type:Organization
Organization Name:ST MARYS HOME CARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RASHAE
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:910-433-4477
Mailing Address - Street 1:3401 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4551
Mailing Address - Country:US
Mailing Address - Phone:910-433-4477
Mailing Address - Fax:910-920-3179
Practice Address - Street 1:3401 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4551
Practice Address - Country:US
Practice Address - Phone:910-433-4477
Practice Address - Fax:910-920-3179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0000251B00000X
NCHC2557251J00000X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601100Medicaid
NC8301378Medicaid
NC8302206Medicaid
NC8700445Medicaid
NC3408108Medicaid