Provider Demographics
NPI:1043451321
Name:AVID HEALTH AT HOME NORTH CAROLINA
Entity type:Organization
Organization Name:AVID HEALTH AT HOME NORTH CAROLINA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-728-4668
Mailing Address - Street 1:1508 MILITARY CUTOFF RD STE 304
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5730
Mailing Address - Country:US
Mailing Address - Phone:910-362-9405
Mailing Address - Fax:910-202-1376
Practice Address - Street 1:58 PHYSICIANS DR NW STE 106
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4216
Practice Address - Country:US
Practice Address - Phone:910-640-1150
Practice Address - Fax:910-640-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC0916251E00000X, 251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601424Medicaid