1679992523 NPI number — PREMIERE HEALTH AND WELLNESS MEDICAL CENTER PLLC

Table of content: (NPI 1679992523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679992523 NPI number — PREMIERE HEALTH AND WELLNESS MEDICAL CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIERE HEALTH AND WELLNESS MEDICAL CENTER 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:
HALIFAX
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:
1679992523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2609 N DUKE ST
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27704-3048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-416-4700
Provider Business Mailing Address Fax Number:
919-416-0821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
608 JACKSON ST
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
ROANOKE RAPIDS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27870-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-416-4700
Provider Business Practice Location Address Fax Number:
919-416-0821
Provider Enumeration Date:
04/08/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PITTS
Authorized Official First Name:
VENUS
Authorized Official Middle Name:
IDETTE
Authorized Official Title or Position:
OWNER/SOLE MEMBER
Authorized Official Telephone Number:
919-416-4700

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 89136E4 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2026035A . This is a "MEDICARE ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".