1053482919 NPI number — TEAM NURSE OF NORTH CAROLINA, INC.

Table of content: (NPI 1053482919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053482919 NPI number — TEAM NURSE OF NORTH CAROLINA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEAM NURSE OF NORTH CAROLINA, INC.
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:
TEAM NURSE - NORTH WILKESBORO
Provider Other Organization Name Type Code:
5
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:
1053482919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 735
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BOSTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24592-0735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-575-5200
Provider Business Mailing Address Fax Number:
434-575-5204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37 BOONE TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH WILKESBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28659-3512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-667-7881
Provider Business Practice Location Address Fax Number:
336-667-7865
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLYNN
Authorized Official First Name:
CHRISTY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
434-575-5200

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HC-2491 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X , with the licence number: HC2491 , 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)

  • Identifier: 3409670 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: HC-2491 . This is a "STATE LICENSURE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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