Provider Demographics
NPI:1306150040
Name:CARDEA HEALTHCARE, LLC
Entity type:Organization
Organization Name:CARDEA HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:CANELAS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MA
Authorized Official - Phone:919-786-5052
Mailing Address - Street 1:8801 FAST PARK DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4852
Mailing Address - Country:US
Mailing Address - Phone:919-786-5052
Mailing Address - Fax:919-786-5067
Practice Address - Street 1:8801 FAST PARK DR
Practice Address - Street 2:SUITE 211
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4852
Practice Address - Country:US
Practice Address - Phone:919-786-5052
Practice Address - Fax:919-786-5067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC4152374U00000X, 3747P1801X, 3747A0650X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418934Medicaid
NC6602072Medicaid