1225645542 NPI number — ISLAND TIME MEDICAL AND WELLNESS, PLLC

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 1225645542 NPI number — ISLAND TIME MEDICAL AND WELLNESS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND TIME MEDICAL AND WELLNESS, 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:
1225645542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3422
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALD HEAD ISLAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28461-7004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-848-8250
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 DOWITCHER TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALD HEAD ISLAND
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-848-8250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2020

Additional Information

Authorized Official

Authorized Official Last Name:
EARNHARDT
Authorized Official First Name:
LOU
Authorized Official Middle Name:
A
Authorized Official Title or Position:
NP / OWNER
Authorized Official Telephone Number:
336-848-8250

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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