1881871622 NPI number — EASTOVER FAMILY CARE PC

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 1881871622 NPI number — EASTOVER FAMILY CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTOVER FAMILY CARE PC
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:
1881871622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3947 DUNN RD # 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASTOVER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28312-8533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-483-6277
Provider Business Mailing Address Fax Number:
910-483-6285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3551 DUNN RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
EASTOVER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28312-8794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-483-6277
Provider Business Practice Location Address Fax Number:
910-483-6285
Provider Enumeration Date:
01/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FARMER
Authorized Official First Name:
VICKIE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
910-483-6277

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2335746 . This is a "MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5908812 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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