1417381195 NPI number — PROGRESSIVE DIABETES CARE, PLLC

Table of content: (NPI 1417381195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417381195 NPI number — PROGRESSIVE DIABETES CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE DIABETES CARE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417381195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
439 WESTWOOD SHOPPING CTR
Provider Second Line Business Mailing Address:
PMB 151
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28314-1532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-491-1727
Provider Business Mailing Address Fax Number:
910-835-2155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
354 WAGONER DR
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28303-3498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-491-1727
Provider Business Practice Location Address Fax Number:
910-835-2155
Provider Enumeration Date:
08/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DOYLE
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER/FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
910-491-1727

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  5003013 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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