Provider Demographics
NPI:1811494107
Name:EXCELLENT SUPPORT CARE CORP.
Entity type:Organization
Organization Name:EXCELLENT SUPPORT CARE CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-995-3112
Mailing Address - Street 1:909 VAN NORDEN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4346
Mailing Address - Country:US
Mailing Address - Phone:862-309-9533
Mailing Address - Fax:
Practice Address - Street 1:909 VAN NORDEN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4346
Practice Address - Country:US
Practice Address - Phone:862-309-9533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1811494107Medicaid