1396049060 NPI number — ARCHDALE FAMILY PRACTICE PA

Table of content: (NPI 1396049060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396049060 NPI number — ARCHDALE FAMILY PRACTICE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARCHDALE FAMILY PRACTICE 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:
1396049060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11635 N MAIN ST STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCHDALE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27263-3271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-861-4110
Provider Business Mailing Address Fax Number:
336-861-4295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11635 N MAIN ST STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCHDALE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27263-3271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-861-4110
Provider Business Practice Location Address Fax Number:
336-861-4295
Provider Enumeration Date:
01/10/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BECK
Authorized Official First Name:
MARK
Authorized Official Middle Name:
CRAIG
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
336-861-4110

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  30119 , 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: 8914271 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".