1003123381 NPI number — DAVIE ALLERGY AND ASTHMA CLINIC, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003123381 NPI number — DAVIE ALLERGY AND ASTHMA CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVIE ALLERGY AND ASTHMA CLINIC, PA
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:
1003123381
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 DORNACH WAY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ADVANCE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27006-7305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-998-3833
Provider Business Mailing Address Fax Number:
336-998-0908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 DORNACH WAY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ADVANCE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27006-7305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-998-3833
Provider Business Practice Location Address Fax Number:
336-998-0908
Provider Enumeration Date:
09/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HERRING
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
SHAREHOLDER
Authorized Official Telephone Number:
336-998-3833

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  2010-00510 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0201X , with the licence number: 2010-00510 , 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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