Provider Demographics
NPI:1861162547
Name:MY PCA- TRIANGLE
Entity type:Organization
Organization Name:MY PCA- TRIANGLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SAN
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-558-8683
Mailing Address - Street 1:5808 KNIGHTDALE BLVD STE 202B
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-8654
Mailing Address - Country:US
Mailing Address - Phone:919-720-1570
Mailing Address - Fax:252-862-2987
Practice Address - Street 1:5808 KNIGHTDALE BLVD STE 202B
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-8654
Practice Address - Country:US
Practice Address - Phone:919-720-1570
Practice Address - Fax:252-862-2987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health