1760417570 NPI number — WAYNESBORO FAMILY CLINIC

Table of content: (NPI 1760417570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760417570 NPI number — WAYNESBORO FAMILY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNESBORO FAMILY CLINIC
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:
1760417570
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1706 WAYNE MEMORIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27534-2240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-734-6676
Provider Business Mailing Address Fax Number:
919-734-9050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1706 WAYNE MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27534-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-734-6676
Provider Business Practice Location Address Fax Number:
919-734-9050
Provider Enumeration Date:
07/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VANNOSKE
Authorized Official First Name:
NITA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
919-734-6676

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , with the licence number: 34D2077478 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 89015MK , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300477 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300477B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6005103 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3410001 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300477G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".