1508230608 NPI number — WAYNE HEALTH VASCULAR AND VEIN CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508230608 NPI number — WAYNE HEALTH VASCULAR AND VEIN CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE HEALTH VASCULAR AND VEIN CENTER 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:
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:
1508230608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 COX BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
GOLDSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27534-9414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-587-3333
Provider Business Mailing Address Fax Number:
919-587-3334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 COX BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
GOLDSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27534-9414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-587-3333
Provider Business Practice Location Address Fax Number:
919-587-3334
Provider Enumeration Date:
11/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
CLYDE
Authorized Official Middle Name:
LOUIS
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
919-587-4081

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  200201214 , 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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