1295993327 NPI number — PINEHURST MEDICAL CLINIC INC

Table of content: (NPI 1295993327)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295993327 NPI number — PINEHURST MEDICAL CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINEHURST MEDICAL CLINIC INC
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:
1295993327
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
705B LAUCHWOOD DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAURINBURG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28352-5544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-266-0111
Provider Business Mailing Address Fax Number:
910-277-0055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705B LAUCHWOOD DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAURINBURG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28352-5544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-266-0111
Provider Business Practice Location Address Fax Number:
910-277-0055
Provider Enumeration Date:
05/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FAIRCLOTH
Authorized Official First Name:
CYRUS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
910-295-5511

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 020R0 . This is a "BC/BS NC GROUP PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5950379 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: NPB301 . This is a "SC MEDICAID GROUP PROVIDER#" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: CC6114 . This is a "PALMETTO GBA GROUP PROVIDER#" identifier . This identifiers is of the category "OTHER".




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