Provider Demographics
NPI:1205937851
Name:HEARTHSIDE HOME CARE INC
Entity type:Organization
Organization Name:HEARTHSIDE HOME CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-455-3176
Mailing Address - Street 1:308 POMONA DR STE JKL
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1665
Mailing Address - Country:US
Mailing Address - Phone:336-808-1351
Mailing Address - Fax:336-808-1458
Practice Address - Street 1:308 POMONA DR STE JKL
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1665
Practice Address - Country:US
Practice Address - Phone:336-808-1351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTHSIDE HOME CARE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-26
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1843251E00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409219Medicaid