1326217399 NPI number — MED MART MEDICAL ASSOCIATES PLLC

Table of content: (NPI 1326217399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326217399 NPI number — MED MART MEDICAL ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED MART MEDICAL ASSOCIATES 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:
1326217399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 S 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LILLINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27546-6690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-893-4111
Provider Business Mailing Address Fax Number:
910-893-9850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7212 GB ALFORD HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLY SPRINGS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27540-7661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-552-1520
Provider Business Practice Location Address Fax Number:
919-552-8792
Provider Enumeration Date:
02/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
REYES
Authorized Official First Name:
RODOLFO
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-893-4111

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  9500701 , 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)





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