1255660353 NPI number — TRIANGLE CHILD ABUSE PEDIATRIC SERVICES, PLLC

Table of content: (NPI 1255660353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255660353 NPI number — TRIANGLE CHILD ABUSE PEDIATRIC SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIANGLE CHILD ABUSE PEDIATRIC SERVICES, 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:
1255660353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1689
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ETOWAH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28729-1689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-891-5524
Provider Business Mailing Address Fax Number:
828-891-4069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 NAVAHO DR
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-7319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-845-4620
Provider Business Practice Location Address Fax Number:
919-846-8126
Provider Enumeration Date:
12/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EVERETT
Authorized Official First Name:
VIVIAN
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-845-4620

Provider Taxonomy Codes

  • Taxonomy code: 2080C0008X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5913571 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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