Provider Demographics
NPI:1487075149
Name:WAKE FOREST BAPTIST HEALTH CARE AT HOME, LLC
Entity type:Organization
Organization Name:WAKE FOREST BAPTIST HEALTH CARE AT HOME, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-814-2077
Mailing Address - Street 1:6330 SPRINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 EXECUTIVE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-7571
Practice Address - Country:US
Practice Address - Phone:336-818-3170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-26
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 171M00000X, 251E00000X
NCHC0430253Z00000X, 332B00000X, 332U00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332U00000XSuppliersHome Delivered Meals
No385H00000XRespite Care FacilityRespite Care
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1487075149Medicaid
347043Medicare Oscar/Certification