1114193695 NPI number — BLADEN HEALTHCARE, LLC

Table of content: (NPI 1114193695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114193695 NPI number — BLADEN HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLADEN HEALTHCARE, LLC
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:
6
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:
1114193695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 A EAST MCKAY STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-862-6308
Provider Business Mailing Address Fax Number:
910-862-5501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28332-8903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-862-3528
Provider Business Practice Location Address Fax Number:
910-862-2207
Provider Enumeration Date:
05/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FISER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
B
Authorized Official Title or Position:
VP MANAGED CARE AND REVENUE CYCLE
Authorized Official Telephone Number:
910-615-5572

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  H0154 , 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: 34-8935A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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