1386620060 NPI number — HEALTHEAST FAMILY CARE OF NAGS HEAD

Table of content: (NPI 1386620060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386620060 NPI number — HEALTHEAST FAMILY CARE OF NAGS HEAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHEAST FAMILY CARE OF NAGS HEAD
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:
1386620060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4810 S CROATAN HIGHWAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
NAGS HEAD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-441-3177
Provider Business Mailing Address Fax Number:
252-441-2271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4810 S CROATAN HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NAGS HEAD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-441-3177
Provider Business Practice Location Address Fax Number:
252-441-2271
Provider Enumeration Date:
12/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LEFFLER
Authorized Official First Name:
VONDA
Authorized Official Middle Name:
GETRUDE
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
252-441-3177

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: 890314E , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0314E . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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